Zachary LaFontaine Objective Data

Objective Data Collection: 24.33 Of 25 (97.32%)

  •  Correct
  •  Partially correct
  •  Incorrect
  •  Missed
 Growth Chart: Head Circumference
1 of 1 point
Head Circumference Percentile (1/2 point)
  •  Below 5th percentile
  •  Between 5th and 95th percentile
  •  Above 95th percentile
Head Circumference Growth Curve (1/2 point)
  •  Growth curve maintained
  •  Growth curve decline
 Growth Chart: Weight and Length
0.83 of 1 point
Length Percentile (1/6 point)
  •  Below 5th percentile
  •  Between 5th and 95th percentile
  •  Above 95th percentile
Length Growth Curve (1/6 point)
  •  Growth curve maintained
  •  Growth curve decline
Weight Percentile (1/6 point)
  •  Below 5th percentile
  •  Between 5th and 95th percentile
  •  Above 95th percentile
Weight Growth Curve (No point)
  •  Growth curve maintained
  •  Growth curve decline
Weight For Length Percentile (1/6 point)
  •  Below 5th percentile
  •  Between 5th and 95th percentile
  •  Above 95th percentile
Weight For Length Growth Curve (1/6 point)
  •  Growth curve maintained
  •  Growth curve decline
 Inspected Nose
1 of 1 point
Nares Inspection (1/3 point)
  •  Pale
  •  Pink
  •  Erythematous
Mucus (1/3 point)
  •  Thin white mucus present
  •  Thick yellow mucus present
Nares (1/3 point)
  •  Patent
  •  Obstructed, not patent single sided
 Inspected Ears
1 of 1 point
Inspection (1/2 point)
  •  Ears set appropriately
  •  Ears low set, posteriorly rotated
Pinna (1/2 point)
  •  Pinna flexible
  •  Pinna stiff
 Inspected Mouth
1 of 1 point
Frenulum (1/4 point)
  •  Frenulum intact
  •  Frenulum thick
Palate (1/4 point)
  •  Palate intact
  •  Palate open
Tongue (1/4 point)
  •  Tongue smooth
  •  Tongue rough
Uvula (1/4 point)
  •  Uvula midline
  •  Uvula absent
 Inspected Skin
1 of 1 point
Color (1/8 point)
  •  Cyanosis
  •  Jaundice
  •  Pallor
  •  Congruent with genetic background
Texture (1/8 point)
  •  Smooth
  •  Rough
Temperature (1/8 point)
  •  Warm
  •  Cool
Skin Hydration (1/8 point)
  •  Elastic
  •  Tenting
  •  Sluggish turgor
Lesions (1/8 point)
  •  No visible lesions
  •  Laceration/wounds
  •  Erythema
  •  Ecchymosis
  •  Birthmark
  •  Discolorations
Mucous Membrane: Hydration (1/8 point)
  •  Moist
  •  Dry
Mucous Membrane: Appearance (1/8 point)
  •  Intact
  •  Cracked
  •  Blistered
Mucous Membrane: Color (1/8 point)
  •  Pink
  •  Pale
  •  Erythematous
 Inspected Diaper Area
1 of 1 point
Inspect Skin Diaper Area (1/1 point)
  •  No lesions present
  •  Macerated
  •  Edema
  •  Erythema
 Inspected Genitalia
1 of 1 point
Appearance (1/5 point)
  •  Urethral meatus midline
  •  Hypospadias
  •  Ambiguous genitalia
Palpation (1/5 point)
  •  Testes present bilaterally
  •  Testes not palpable
Rugae (1/5 point)
  •  Smooth
  •  Rough
Masses (1/5 point)
  •  No masses
  •  Mass palpable
  •  Swelling
Circumcision (1/5 point)
  •  Circumcised
  •  Uncircumcised
 Assessed Musculoskeletal: Barlow and Ortolani
1 of 1 point
Barlow (1/2 point)
  •  Positive
  •  Negative
Ortolani (1/2 point)
  •  Positive
  •  Negative
 Assessed Eyes: Pupils
1 of 1 point
Shape (1/3 point)
  •  Round
  •  Abnormal shape
Light Reaction (1/3 point)
  •  No reaction to light
  •  Reacts to light symmetrically
  •  Reacts to light asymmetrically
Opacity (1/3 point)
  •  Clear
  •  Cloudy
 Assessed Eyes: Red Reflex
1 of 1 point
Red Reflex (1/3 point)
  •  Absent
  •  Present
Color (1/3 point)
  •  Equal color bilaterally
  •  Unequal color bilaterally
Opacity (1/3 point)
  •  Opacity absent
  •  Opacity present
 Assessed Eyes: Tracking
1 of 1 point
Vision Screening (1/1 point)
  •  Follows object in both directions
  •  Does not follow object in both directions
 Assessed Extremities
1 of 1 point
Movement (1/2 point)
  •  Moves all extremities
  •  Does not move all extremities
Symmetry (1/2 point)
  •  Movement symmetrical
  •  Movement asymmetrical
 Assessed Grasp
1 of 1 point
Grasp (1/3 point)
  •  Intact
  •  Not Evident
Tone (1/3 point)
  •  Strong
  •  Weak
Symmetry (1/3 point)
  •  Symmetrical
  •  Asymmetrical
  •  Absent
 Assessed Moro Reflex
1 of 1 point
Moro Reflex (1/2 point)
  •  Normal Response
  •  Weak response
  •  Absent response
Hearing (1/2 point)
  •  Hearing intact
  •  Hearing absent
 Assessed Tonic Reflex
1 of 1 point
Neck Range Of Motion (1/2 point)
  •  Symmetrical
  •  Asymmetrical
  •  Absent
Tonic Reflex (1/2 point)
  •  Present
  •  Absent
 Assessed Pulse
1 of 1 point
Pulse (1/2 point)
  •  Regular
  •  Irregular
Amplitude (1/2 point)
  •  Equal bilaterally
  •  0
  •  +1
  •  +2
  •  +3
 Assessed Rooting Reflex
1 of 1 point
Rooting Reflex (1/1 point)
  •  Normal response
  •  Weak response
  •  Absent response
 Assess Sucking Reflex
1 of 1 point
Sucking Reflex (1/2 point)
  •  Normal response
  •  Weak response
  •  Absent response
Tongue Range Of Motion (1/2 point)
  •  Normal response
  •  Absent response
 Assessed Neurological: Stepping/Walking Reflex
1 of 1 point
Stepping Relfex (1/1 point)
  •  Present
  •  Absent
 Palpated Abdomen
1 of 1 point
Light Palpation (1/2 point)
  •  Soft
  •  Firm
  •  Distended
  •  Mass
  •  Bulges
Tenderness (1/2 point)
  •  Nontender
  •  Tender
 Palpated Fontanelles
1 of 1 point
Anterior (1/2 point)
  •  Sunken
  •  Flat
  •  Bulging
Posterior (1/2 point)
  •  Sunken
  •  Flat
  •  Bulging
 Auscultated Abdomen
0.5 of 1 point
Appearance (No point)
  •  Protuberant
  •  Flat
  •  Scaphoid
Auscultation (1/2 point)
  •  Absent
  •  Hypoactive
  •  Normoactive
  •  Hyperactive
 Auscultated Heart
1 of 1 point
Rate (1/3 point)
  •  Regular Rate
  •  Irregular Rate
Rhythm (1/3 point)
  •  Regular rhythm
  •  Arrhythmia
Heart Sounds (1/3 point)
  •  S1
  •  S2
  •  S3
  •  S4
  •  Murmurs
 Auscultated Lungs
1 of 1 point
Appearance (1/3 point)
  •  Symmetrical chest rise
  •  Asymmetrical chest rise
Breath Sounds (1/3 point)
  •  Clear to auscultation
  •  Wheezing
  •  Stridor
  •  Grunting
  •  Absent
Respiratory Effort (1/3 point)
  •  Smooth, even respirations
  •  Nasal flaring
  •  Retractions

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