Here is an example:
Part of OBX5:
PHYSICAL EXAMINATION: This baby’s head circumference is 34.5 cm. She is~ hydrocephalic. That is up from 34 cm yesterday after her tap. She is~ pale-pink and asleep in an open crib. ~~VS: Stable.~Genera
l: Active infant in room air.~Chest: Clear and equal breath sounds bilaterally.~Heart: NSR, no murmur, two sec CRT, +2 pulses.~Abdomen: Soft, nondistended, positive bowel sounds.~Neuro: Good symmetrical tone, anterior fontanel soft and flat.~~ASSESSMENT/PLAN: ~1) Respiratory. This infant continues in room air with no apnea or~ bradycardia. We will continue to monitor her closely. ~~2) Fluids and nutrition. The baby is feeding Similac Special Care ~ 20-Calorie Formula, 40 ml every three hours, which gives her ~ 171 ml/kg/day. She is nippling all of her feedings; stooling; and~ voiding. ~~
This is what is translated:
PHYSICAL EXAMINATION: This baby’s head circumference is 34.5 cm. She is
Any help is greatly appreciated…
Mary