Well Child Check Visit Notes

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NEWBORN WT/COLOR CHECK
 
SUBJECTIVE:
_-day old infant born to a _ year old G_ at _ weeks by _. No pregnancy or delivery problems.
Mother was blood type _, HBsAg neg, rubella immune, GBS _, other labs also unremarkable. In
the hospital, the patient received the initial HBV vaccine, passed the hearing screen, and had
normal pulse ox screening.
Since going home, the patient has been feeding well, stooling/voiding normally, and behaving
normally. The mother has no concerns/questions today.
DEVELOPMENT:
- Gross motor: Lifts head.
- Fine motor: Moving all limbs equally.
- Cognitive: Eyes appear to fix on objects/lights.
- Social/Emotional: Appears to regard faces of others (at about 12 inches).
- Communication: Behaving normally.
SOCIAL HX:
No smokers in the home. Stable, tranquil family. No major social stressors at home. Mother is
doing well.
FAMILY HX:
No h/o SIDS, atopic disease
OBJECTIVE:
- VITALS: _
- WEIGHTS: BW _. Today's weight _.
- GEN: Normal general appearance. NAD.
- HEAD: NCAT. No cephalohematoma. AFOSF.
- EENT: Red reflex present bilaterally. Normal ext ears, nose, lips.
- MOUTH: MMM. Normal gums, mucosa, palate, OP.
- NECK: Supple.
- CV: RRR, no m/r/g. Normal femoral pulses.
- LUNGS: CTAB, no w/r/c.
- ABD: Soft, NT/ND, NBS, no masses or organomegaly. Normal umbilical stump without surrounding erythema. Anus & perineum normal. No hernias.
- GU: Normal _male genitalia. Testes descended bilaterally.
- SKIN: WWP. No jaundice, new skin rashes, or abnormal lesions. No sacral dimple.
- MSK: Normal extremities & spine. No hip clicks or clunks. No clavicular fracture.
- NEURO: MAE symmetrically. Normal moro & suck reflexes. Normal muscle tone.
ASSESSMENT/PLAN:
* Healthy newborn infant, doing well.
- Routine care. Encouraged breastfeeding.
- F/u at 2 weeks of age, or sooner PRN.
* Anticipatory guidance (discussed or covered in a handout given to the family)
- Normal newborn feeding and sleep patterns
- Infant should always sleep on back to prevent SIDS
- Tummy time
- No smoking in home: risk for SIDS and asthma
- Safest to sleep in crib or bassinet
- Car seat facing backward until 2 years of age and 20 pounds
- Working smoke alarms and carbon dioxide monitors in home
- Hot water heater to less than 120 degrees
- Normal crying versus colic, and what to expect
- Warning signs for postpartum depression versus baby blues
- Signs of jaundice
- Sibling envy
- Poly-Vi-Sol to supplement with iron if mostly breast feeding
- How and when to contact us
2 WEEKS
 
SUBJECTIVE:
2-week old infant born to a _ year old G_ at _. No parental concerns/questions today.
ROS:
- Eating well: _
- No concerns about stooling or voiding.
PM/SH:
Normal pregnancy and delivery.
DEVELOPMENT:
- Gross motor: Lifts head when on tummy.
- Fine motor: Moving all limbs equally.
- Cognitive: Starting to smile. Eyes are tracking objects/bright lights.
- Social/Emotional: + consolable. Appears to regard faces of others (at about 12 inches).
- Communication: Coos.
SOCIAL HX:
No smokers in the home. Stable, tranquil family. No major social stressors at home. Mother is doing well.
FAMILY HX:
No h/o SIDS, atopic disease
OBJECTIVE:
- VITALS: _
- WEIGHTS: BW _. Today's weight _.
- GEN: Normal general appearance. NAD.
- HEAD: NCAT. No cephalohematoma. AFOSF.
- EENT: Red reflex present bilaterally. Normal ext ears, nose, lips.
- MOUTH: MMM. Normal gums, mucosa, palate, OP.
- NECK: Supple.
- CV: RRR, no m/r/g. Normal femoral pulses.
- LUNGS: CTAB, no w/r/c.
- ABD: Soft, NT/ND, NBS, no masses or organomegaly. Normal umbilicus.
- GU: Normal _male genitalia. Testes descended bilaterally.
- SKIN: WWP. No jaundice, new skin rashes, or abnormal lesions. No sacral dimple.
- MSK: Normal extremities & spine. No hip clicks or clunks. No clavicular fracture.
- NEURO: MAE symmetrically. Normal moro & suck reflexes. Normal muscle tone.
NEWBORN SCREEN:
- Results all negative.
ASSESSMENT/PLAN:
* Healthy 2-week old infant, doing well.
- F/u at 6-8 weeks of age, or sooner PRN.
* Anticipatory guidance (discussed or covered in a handout given to the family)
- Normal newborn feeding and sleep patterns
- Infant should always sleep on back to prevent SIDS
- Tummy time
- Range of normal bowel habits
- No smoking in home: risk for SIDS and asthma
- Safest to sleep in crib or bassinet
- Car seat facing backward until 2 years of age and 20 pounds
- Working smoke alarms and carbon dioxide monitors in home
- No smokers in the home
- Hot water heater to less than 120 degrees
- Fall prevention
- Normal crying versus colic, and what to expect
- Warning signs for postpartum depression versus baby blues
- Sibling envy
- No honey, corn syrup, cows milk until 1 year
- Formula mixing
- Poly-Vi-Sol supplement with iron if mostly breast feeding (< 32 oz/day of formula)
- How and when to contact us
6-8 WEEKS
 
SUBJECTIVE:
_-week old infant here for a routine well child check and vaccines. No parental concerns/ questions today.
ROS:
- Eating well: _
- Stooling/voiding normally.
- Behaving normally.
- No concerns about sleep at this time.
PM/SH:
Normal pregnancy and delivery. No surgeries, hospitalizations, or serious illnesses to date.
DEVELOPMENT:
- Gross motor: Able to hold head somewhat steady when pulled to a sitting position. Able to push body up when prone.
- Fine motor: Moving all extremities symmetrically. Can hold an object briefly.
- Cognitive: Indicates boredom when minimal stimulation. Eyes track well, and can fix on objects.
- Social/Emotional: Smiles, looks at parents, able to comfort self.
- Communication: Coos, vocalizes. Has different cries for different needs.
SOCIAL HX:
No smokers in the home. Stable, tranquil family. No major social stressors at home. Mother is doing well. Daytime care is _
FAMILY HX:
No h/o SIDS, atopic disease
OBJECTIVE:
- VITALS: _
- WEIGHTS: BW _. Today's weight _.
- GEN: Normal general appearance. NAD.
- HEAD: NCAT. AFOSF.
- EYES: Red reflex present bilaterally. Light reflex symmetric. EOMI, with no strabismus.
- ENMT: TMs, nares, and OP normal. MMM. No abnormal oral lesions.
- NECK: Supple, with no masses.
- CV: RRR, no m/r/g. Normal femoral pulses.
- LUNGS: CTAB, no w/r/c.
- ABD: Soft, NT/ND, NBS, no masses or organomegaly.
- GU: Normal _male genitalia. Testes descended bilaterally.
- SKIN: WWP. No jaundice, new skin rashes, or abnormal lesions.
- MSK: Normal extremities & spine. No hip clicks or clunks.
- NEURO: MAE symmetrically. Normal muscle strength and tone.
NEWBORN SCREEN:
- Results all negative.
ASSESSMENT/PLAN:
* Healthy newborn infant, doing well.
- Routine care.
- F/u at 4 months of age, or sooner PRN.
* Vaccines today:
- Pediarix #1 (DTaP, IPV, HepB #2), PCV #1, Rota #1, Hib #1
- Pentacel #1 (DTaP, IPV, Hib), PCV #1, Rota #1, HepB #2
- Comvax (Hib #1, HepB #2), PCV #1, Rota #1, DTaP #1, IPV #1
* Anticipatory guidance (discussed or covered in a handout given to the family)
- Common immunization SE’s
- Nutrition and feeding; growth spurts
- Normal sleep patterns. Infant should always sleep on back to prevent SIDS
- Tummy time
- Range of normal bowel habits
- No smoking in home: risk for SIDS and asthma
- Safest to sleep in crib or bassinet
- Car seat facing backward until 2 years of age (ideally 2) and 20 pounds
- Working smoke alarms and carbon dioxide monitors in home
- No smokers in the home
- Hot water heater to less than 120 degrees
- Fall prevention
- Normal crying versus colic, and what to expect
- Warning signs for postpartum depression versus baby blues
- Sibling adjustment
- No honey, corn syrup, cows milk until 1 year
- Formula mixing
- Poly-Vi-Sol supplement with iron if mostly breast feeding (< 32 oz/day of formula)
- How and when to contact us
4 MONTHS
 
SUBJECTIVE:
4-month old infant here for a well child check. No parental concerns/questions today.
ROS:
- Eating well: _
- Hasn’t tried solids yet.
- No concerns about stooling or voiding.
- Bedtime routine: _
PM/SH:
Normal pregnancy and delivery. No surgeries, hospitalizations, or serious illnesses to date.
DEVELOPMENT:
- Gross motor: Good head control, including when prone. Good head control when pulled to a sitting position.
- Fine motor: Able to roll from front to back. Reaches for objects, and holds them briefly.
- Cognitive: Responds to affection. Indicates pleasure and displeasure.
- Social/Emotional: Laughs, squeals. Can self-calm.
- Communication: Babbles, smiles.
SOCIAL:
- No smokers in the home.
- No postpartum depression in mother.
- No major social stressors at home.
- Daytime child care is with _
- No TB risk factors.
OBJECTIVE:
- VITALS: _
- GEN: Normal general appearance. NAD.
- HEAD: NCAT. AFOSF.
- EYES: Red reflex present bilaterally. Light reflex symmetric. EOMI, with no strabismus.
- ENMT: TMs, nares, and OP normal. MMM. No abnormal oral lesions.
- NECK: Supple, with no masses.
- CV: RRR, no m/r/g. Normal femoral pulses.
- LUNGS: CTAB, no w/r/c.
- ABD: Soft, NT/ND, NBS, no masses or organomegaly.
- GU: Normal _male genitalia. Testes descended bilaterally.
- SKIN: WWP. No skin rashes or abnormal lesions.
- MSK: Normal extremities & spine. No hip clicks or clunks.
- NEURO: MAE symmetrically. Normal muscle strength and tone.
GROWTH CHART: Following growth curve well in all parameters.
ASSESSMENT/PLAN:
* Healthy 4-month old infant
- Follow up at 6 months of age, or sooner PRN.
- ER/return precautions discussed.
* Vaccines today:
- Pediarix #2 (DTaP, IPV, HepB #3), PCV #2, Rota #2, Hib #2
- Pentacel #2 (DTaP, IPV, Hib), PCV #2, Rota #2, HepB #3
- Comvax (Hib #2, HepB #3), PCV #2, Rota #2, DTaP #2, IPV #2
* Premature (< 37 weeks) or < 5.5 lbs
- Consider hemoglobin
* Anticipatory guidance (discussed or covered in a handout given to the family)
- Common immunization SE’s
- How and when to introduce solids
- Normal sleep patterns (decreased nighttime feeds, more regular sleep patterns)
- Infant should always sleep on back to prevent SIDS (first 6 months, at least)
- Teething (first tooth at 3-12 months, average 7 months)
- Tummy time; prevention of plagiocephaly
- Range of normal bowel habits
- Warning signs for postpartum depression versus baby blues
- No smoking in home: risk for SIDS and asthma
- Safest to sleep in crib or bassinet
- Car seat facing backward until 2 years of age and 20 pounds
- Working smoke alarms and carbon dioxide monitors in home
- Hot water heater to less than 120 degrees
- Fall prevention
- Normal crying versus colic, and what to expect
- No honey, corn syrup, cows milk until 1 year
- Poly-Vi-Sol supplement with iron if mostly breast feeding (< 32 oz/day of formula)
- How and when to contact us
6 MONTHS
 
SUBJECTIVE:
6 month old _ here for well child check. No parental concerns at this time.
REVIEW OF SYSTEMS:
- Diet: No concerns. Starting to try solids.
- Voiding/stooling: No concerns.
- Sleeping: Has a regular bedtime routine, and sleeps through the night without feeding.
- Behavior: No concerns.
PM/SH:
Normal pregnancy and delivery. No surgeries, hospitalizations, or serious illnesses to date.
DEVELOPMENT:
- Gross and fine motor: Head flexed forward when pulled to a sitting position. Is able to sit up, rolls over both ways. Reaches and grabs; raking grasps.
- Cognitive: Responds to affection. Turns towards sounds.
- Social/Emotional/Communication: Smiles, laughs, likes to talk and play.
SOCIAL:
- No smokers in the home.
- No concerns regarding postpartum depression.
- No major social stressors at home.
- No safety concerns in the home.
- Daytime child care is with _
- No TB or lead risk factors.
IMMUNIZATIONS:
- Up to date.
OBJECTIVE:
- VITALS: _
- GEN: Normal general appearance. NAD.
- HEAD: NCAT. AFOSF.
- EYES: Red reflex present bilaterally. Light reflex symmetric. EOMI, with no strabismus.
- ENMT: TMs, nares, and OP normal. MMM. No abnormal oral lesions.
- NECK: Supple, with no masses.
- CV: RRR, no m/r/g. Normal femoral pulses.
- LUNGS: CTAB, no w/r/c.
- ABD: Soft, NT/ND, NBS, no masses or organomegaly.
- GU: Normal _male genitalia. Testes descended bilaterally.
- SKIN: WWP. No skin rashes or abnormal lesions.
- MSK: Normal extremities & spine. No hip clicks or clunks.
- NEURO: MAE symmetrically. Normal muscle strength and tone.
- GROWTH CHART: Following growth curve nicely in all parameters.
ASSESSMENT/PLAN:
* Healthy 6-month old infant
- The family was given a children’s book today (per “Reach Out and Read” program)
- Follow up at 9 months of age, or sooner PRN.
- ER/return precautions discussed.
* Vaccines today:
- Pediarix #3 (DTaP, IPV, HepB #4), PCV #3, Rota #3, Hib #3, Influenza
- Pentacel #3 (DTaP, IPV, Hib), PCV #3, Rota #3, HepB #4, Influenza
- PCV #3, Rota #3, DTaP #3, IPV #3, Influenza (Hib, HepB to be given at 12-month visit)
* Anticipatory guidance (discussed or covered in a handout given to the family)
- Common immunization SE’s
- Avoiding use of walkers and door swings/jumpers.
- Child proofing the home: Gates for stairs, burn prevention, kitchen safety, water safety
- Poison Control number (800-222-1222)
- Car seat facing backward until 2 years of age and 20 pounds
- Teething and fluoride (first tooth at 3-12 months, average 7 months)
- How and when to introduce solids: Iron-fortified foods, delaying sweet foods and fruits, no honey/corn syrup/cow’s milk until one year old, finger foods
- Choking hazards
- No juice from bottle; no bottle in bed; early use of sippy cup
- Speech development (importance of reading and talking)
- Sleep: Separation anxiety, night awakening, sleep training, lower crib mattress, side rales up
- Warning signs for postpartum depression versus baby blues
9 MONTHS
SUBJECTIVE:
9 month old _ here for well child check. No parental concerns at this time.
REVIEW OF SYSTEMS:
- Diet: No concerns.
- Voiding/stooling: No concerns.
- Sleeping: Has a regular bedtime routine, and sleeps through the night without feeding.
- Behavior: No concerns.
PM/SH:
Normal pregnancy and delivery. No surgeries, hospitalizations, or serious illnesses to date.
DEVELOPMENT:
- Gross motor: Sits well on own, crawls, cruises, pulls self to stand (with help)
- Fine motor: Uses pincer grasp, takes finger foods.
- Cognitive: +object permanence, likes to look at books.
- Social/Emotional: Laughs, likes to play games (e.g. “peek-a-boo”), early signs of stranger anxiety, seeks parents for comfort.
- Communication: Understands a few words, babbles, imitates sounds, says nonspecific syllables (“mama,” “dada”), points out objects.
SOCIAL:
- No smokers in the home.
- No concerns regarding postpartum depression.
- No major social stressors at home.
- No safety concerns in the home.
- Daytime child care is with _
- No TB or lead risk factors.
IMMUNIZATIONS:
- Up to date.
OBJECTIVE:
- VITALS: _
- GEN: Normal general appearance. NAD.
- HEAD: NCAT. Anterior fontanelle _
- EYES: Red reflex present bilaterally. Light reflex symmetric. EOMI, with no strabismus.
- ENMT: TMs, nares, and OP normal. MMM. No abnormal oral lesions.
- NECK: Supple, with no masses.
- CV: RRR, no m/r/g. Normal femoral pulses.
- LUNGS: CTAB, no w/r/c.
- ABD: Soft, NT/ND, NBS, no masses or organomegaly.
- GU: Normal _male genitalia. Testes descended bilaterally.
- SKIN: WWP. No skin rashes or abnormal lesions.
- MSK: Normal extremities & spine. No hip clicks or clunks.
- NEURO: MAE symmetrically. Normal muscle strength and tone.
GROWTH CHART: Following growth curve nicely in all parameters.
ASSESSMENT/PLAN:
* Healthy 9-month old infant
- The family was given a children’s book today (per “Reach Out and Read” program)
- Follow up at 12 months of age, or sooner PRN.
- ER/return precautions discussed.
* Vaccines today:
- Influenza
- None
* Anticipatory guidance (discussed or covered in a handout given to the family)
- Avoiding use of walkers and door swings/jumpers.
- Child proofing the home: Gates for stairs, burn prevention, kitchen safety, water safety
- Poison Control number (800-222-1222)
- Car seat facing backward until 2 years of age and 20 pounds
- Dental care and fluoride (first tooth at 3-12 months, average 7 months)
- Food: Iron-fortified foods, no honey/corn syrup/cow’s milk until one year old, finger foods, no/minimal juice
- Choking hazards
- No juice from bottle; no bottle in bed; introducing a sippy cup
- Speech development (importance of reading and talking)
- Sleep: Separation anxiety, night awakening, sleep training, lower crib mattress, side rales up
ONE YEAR
 
SUBJECTIVE:
_-month old _ here for well child check. No parental concerns at this time.
REVIEW OF SYSTEMS:
- Diet: No concerns.
- Voiding/stooling: No concerns.
- Sleeping: Has regular bedtime routine, and sleeps through the night without feeding.
- Behavior: No concerns.
- Activity: Screen/TV time is limited to < 2 hrs/day.
PM/SH:
Normal pregnancy and delivery. No surgeries, hospitalizations, or serious illnesses to date.
DEVELOPMENT:
- Gross motor: Pulls self to a stand, cruises. Starting to walk.
- Fine motor: Uses pincer grasp, feeds self, bangs toys together, drinks from a cup.
- Cognitive: Follows simple directions, hands adults books to read.
- Social/Emotional: Laughs, likes to play games (e.g. “peek-a-boo”), + stranger anxiety, looks at parent when name is called, waves bye-bye, tries to copy adults and older children.
- Communication: Knows 1-2 words, babbles, imitates sounds, uses gestures.
SOCIAL:
- No smokers in the home.
- No concerns regarding postpartum depression.
- No major social stressors at home.
- No safety concerns in the home.
- Daytime child care is with _
- No TB or lead risk factors.
IMMUNIZATIONS:
- Up to date.
OBJECTIVE:
- VITALS: _
- GEN: Normal general appearance. NAD.
- HEAD: NCAT.
- EYES: PERRL, red reflex present bilaterally. Light reflex symmetric. EOMI, with no strabismus.
- ENMT: TMs, nares, and OP normal. MMM. Normal gums, mucosa, palate. Good dentition.
- NECK: Supple, with no masses.
- CV: RRR, no m/r/g.
- LUNGS: CTAB, no w/r/c.
- ABD: Soft, NT/ND, NBS, no masses or organomegaly.
- GU: Normal _male genitalia. Testes descended bilaterally.
- SKIN: WWP. No skin rashes or abnormal lesions.
- MSK: Normal extremities & spine.
- NEURO: MAE symmetrically. Normal muscle strength and tone.
GROWTH CHART: Following growth curve well in all parameters.
ASSESSMENT/PLAN:
* Healthy _-month old toddler
- The family was given a children’s book today (per “Reach Out and Read” program).
- The family was given a list of dentists in the county who take MediCal.
- CBC and lead level ordered.
- Follow up at 15 months of age, or sooner PRN.
- ER/return precautions discussed.
* Vaccines today:
- ProQuad #1 (MMR, Varicella), HepA #1, PCV #4, Hib #4, Influenza
- ProQuad #1 (MMR, Varicella), HepA #1, PCV #4, Influenza
- ProQuad #1 (MMR, Varicella), Comvax (Hib #3, HepB #4), HepA #1, PCV #4, Influenza
* Anticipatory guidance (discussed or covered in a handout given to the family)
- Common immunization SE’s
- Safety: Child-proofed home, burn prevention, kitchen safety, water safety, firearms, sunscreen, Poison Control number (800-222-1222)
- Car seat facing backward until 2 years of age and 20 pounds
- Dental care and fluoride; dental visits
- Food: Fortified whole milk (2 cups/day), limiting juice and sweets, finger foods, picky eating.
- Transitioning from bottle to cups; no bottle in bed
- Choking hazards
- Discipline: Praising wanted behaviors, distraction, setting limits, routines.
- Emerging independence (offer choices)
- Speech development (importance of reading and talking)
- Sleep: Sleep hygiene, dreams
15 MONTHS
 
SUBJECTIVE:
_-month old _ here for well child check. No parental concerns at this time.
REVIEW OF SYSTEMS:
- Diet: No concerns.
- Voiding/stooling: No concerns.
- Sleeping: Has regular bedtime routine, and sleeps through the night without feeding.
- Behavior: No concerns.
- Activity: Screen/TV time is limited to < 2 hrs/day.
PM/SH:
Normal pregnancy and delivery. No surgeries, hospitalizations, or serious illnesses to date.
DEVELOPMENT:
- Gross motor: Walking, starting to run, bends down without falling.
- Fine motor: Feeds self with a spoon, puts blocks in a cup, drinks from a cup with very little spilling.
- Cognitive: Follows simple directions, scribbles.
- Social/Emotional: Pretend play (e.g. phone), stranger anxiety, likes to copy older children and adults, tries to help.
- Communication: Knows at least 4 words, points to body parts, brings toys over to show you.
SOCIAL:
- No smokers in the home.
- No major social stressors at home.
- No safety concerns in the home.
- Daytime child care is with _
- No TB or lead risk factors.
IMMUNIZATIONS:
- Up to date.
OBJECTIVE:
- VITALS: _
- GEN: Normal general appearance. NAD.
- HEAD: NCAT.
- EYES: PERRL, red reflex present bilaterally. Light reflex symmetric. EOMI, with no strabismus.
- ENMT: TMs, nares, and OP normal. MMM. Normal gums, mucosa, palate. Good dentition.
- NECK: Supple, with no masses.
- CV: RRR, no m/r/g.
- LUNGS: CTAB, no w/r/c.
- ABD: Soft, NT/ND, NBS, no masses or organomegaly.
- GU: Normal _male genitalia. Testes descended bilaterally.
- SKIN: WWP. No skin rashes or abnormal lesions.
- MSK: Normal extremities & spine.
- NEURO: Normal muscle strength and tone. No focal deficits.
GROWTH CHART: Following growth curve well in all parameters.
ASSESSMENT/PLAN:
* Healthy _-month old toddler
- The family was given a children’s book today (per “Reach Out and Read” program).
- The family was given a list of dentists in the county who take MediCal.
- CBC and lead level ordered.
- Follow up at 18 months of age, or sooner PRN.
- ER/return precautions discussed.
* Vaccines today:
- DTaP #4, Influenza
- Pentacel #4 (DTaP, IPV, Hib), Influenza
* Anticipatory guidance (discussed or covered in a handout given to the family)
- Common immunization SE’s
- Safety: Child-proofed home, burn prevention, kitchen safety, water safety, firearms, sunscreen, Poison Control number (800-222-1222)
- Car seat facing backward until 2 year of age and 20 pounds
- Dental care and fluoride; dental visits
- Food: Picky eating, fortified whole milk, limiting juice and junk/fast food.
- Transitioning from bottle to cups; no bottle in bed
- Discipline: Praising wanted behaviors, distraction, setting limits, routines.
- Emerging independence (offer choices)
- Speech development (importance of reading and talking)
- Sleep: Nightmares, sleep hygiene
- Limiting screen time
- Hazards of second hand smoke
18 MONTHS
 
SUBJECTIVE:
_-month old _ here for well child check. No parental concerns at this time.
REVIEW OF SYSTEMS:
- Diet: No concerns. Weaned from bottle.
- Voiding/stooling: No concerns. + showing interest in potty.
- Sleeping: Has regular bedtime routine, and sleeps through the night without feeding.
- Behavior: No concerns.
- Activity: Screen/TV time is limited to < 2 hrs/day.
PM/SH:
Normal pregnancy and delivery. No surgeries, hospitalizations, or serious illnesses to date.
DEVELOPMENT:
- Gross motor: Runs, walks up steps, able to kick a ball.
- Fine motor: Feeds self with a spoon, removes clothes, stacks 2 blocks, uses spoon and cup
without spilling most of the time.
- Cognitive: Follows simple directions, scribbles, knows name of favorite book.
- Social/Emotional: Helps in the house, laughs in response to others, points out things of interest.
- Communication: Knows at least 4-10 words, points to at least one body part.
- Autism Screening: MCHAT score: _. Seems to interact with others well. Makes eye contact.
- Enjoys pretend play. Orients to name. Points and gestures socially. Using 2-word phrases.
SOCIAL:
- No smokers in the home.
- No major social stressors at home.
- No safety concerns in the home.
- Daytime child care is with _
- No TB or lead risk factors.
IMMUNIZATIONS:
- Up to date.
OBJECTIVE:
- VITALS: _
- GEN: Normal general appearance. NAD.
- HEAD: NCAT.
- EYES: PERRL, red reflex present bilaterally. Light reflex symmetric. EOMI, with no strabismus.
- ENMT: TMs, nares, and OP normal. MMM. Normal gums, mucosa, palate. Good dentition.
- NECK: Supple, with no masses.
- CV: RRR, no m/r/g.
- LUNGS: CTAB, no w/r/c.
- ABD: Soft, NT/ND, NBS, no masses or organomegaly.
- GU: Normal _male genitalia. Testes descended bilaterally.
- SKIN: WWP. No skin rashes or abnormal lesions.
- MSK: Normal extremities & spine.
- NEURO: Normal muscle strength and tone. No focal deficits.
GROWTH CHART: Following growth curve well in all parameters.
ASSESSMENT/PLAN:
* Healthy _-month old toddler
- The family was given a children’s book today (per “Reach Out and Read” program).
- MCHAT done today - No concerns.
- The family was given a list of dentists in the county who take MediCal.
- Follow up at 2 years of age, or sooner PRN.
- ER/return precautions discussed.
* Vaccines today:
- HepA #2, Influenza
* Anticipatory guidance (discussed or covered in a handout given to the family)
- Common immunization SE’s
- Safety: Child-proofed home, burn prevention, kitchen safety, water safety, firearms, sunscreen, Poison Control number (800-222-1222)
- Car seat facing backward until 2 years of age (ideally 2) and 20 pounds
- Dental care and fluoride; dental visits
- Food: Picky eating, fortified whole milk, limiting juice and junk/fast food.
- Transitioning from bottle to cups; no bottle in bed
- Discipline: Praising wanted behaviors, distraction, time outs, setting limits, routines.
- Emerging independence (offer choices)
- Growing vocabulary (importance of reading and talking)
- Limiting screen time
- Sleep: Nightmares, sleep hygiene
- Hazards of second hand smoke
2 YEARS
 
SUBJECTIVE:
2yo _ here for well child check. No parental concerns at this time.
REVIEW OF SYSTEMS:
- Diet: No concerns. Weaned from bottle.
- Voiding/stooling: No concerns. Working on toilet training.
- Sleeping: No concerns. Has regular bedtime routine.
- Dental: Weaned from the bottle. + brushes teeth with help. Has already been to the dentist.
- Behavior: No concerns.
- Activity: Screen/TV time is limited to < 2 hrs/day.
PM/SH:
Normal pregnancy and delivery. No surgeries, hospitalizations, or serious illnesses to date.
DEVELOPMENT:
- Gross motor: Walks up/down steps, able to kick a ball, jumps in place, throws a ball overhand.
- Fine motor: Turns a page one at a time, removes clothes, stacks 5-6 blocks.
- Cognitive: Follows 2-step commands, scribbles, names items in pictures, uses spoon and cup well.
- Social/Emotional: Copies adults, plays pretend, plays well alongside other children.
- Communication: Able to put 2 words together, knows 20+ words.
- Autism Screening: MCHAT score: _. Seems to interact with others well. Makes eye contact.
- Enjoys pretend play. Orients to name. Points and gestures socially. Using 2-word phrases.
SOCIAL:
- No smokers in the home.
- No major social stressors at home.
- No safety concerns in the home.
- Daytime child care is with _
- No TB or lead risk factors.
IMMUNIZATIONS:
- Up to date.
OBJECTIVE:
- VITALS: _
- GEN: Normal general appearance. NAD.
- HEAD: NCAT.
- EYES: PERRL, red reflex present bilaterally. Light reflex symmetric. EOMI, with no strabismus.
- ENMT: TMs, nares, and OP normal. MMM. Normal gums, mucosa, palate. Good dentition.
- NECK: Supple, with no masses.
- CV: RRR, no m/r/g.
- LUNGS: CTAB, no w/r/c.
- ABD: Soft, NT/ND, NBS, no masses or organomegaly.
- GU: Normal _male genitalia. Testes descended bilaterally.
- SKIN: WWP. No skin rashes or abnormal lesions.
- MSK: Normal extremities & spine.
- NEURO: Normal muscle strength and tone. No focal deficits.
GROWTH CHART: Following growth curve well in all parameters. BMI at _ percentile.
ASSESSMENT/PLAN:
* Healthy 2yo toddler
- CBC and lead level ordered.
- The family was given a children’s book today (per “Reach Out and Read” program).
- MCHAT done today - No concerns.
- The family was given a list of dentists in the county who take MediCal.
- Follow up at 2.5 years of age, or sooner PRN.
- ER/return precautions discussed.
* Vaccines today:
- Influenza
- None
* Anticipatory guidance (discussed or covered in a handout given to the family)
- Safety: Street/car safety, water safety, toxins, gun safety.
- Booster seat required by law until 8 yrs old or 4’9”
- Food: Picky eating, fortified 2% milk, limiting juice and junk/fast food.
- Development: Toilet training, limiting screen time.
- Discipline: Praising wanted behaviors, tantrum management, time outs, setting limits, routines, offering choices, don’t expect sharing.
- Speech: Normal speech dysfluency, importance of reading to child.
- Dental care and fluoride; dental visits
- Sleep: Nightmares, sleep hygiene
- Hazards of second hand smoke
3 YEARS
 
SUBJECTIVE:
3 yo _ here for well child check. No parental concerns at this time.
REVIEW OF SYSTEMS:
- Diet: No concerns.
- Voiding/stooling: No concerns. + toilet trained (during the day, at least).
- Sleeping: No concerns. Has regular bedtime routine.
- Dental: Weaned from the bottle. + brushes teeth. Has been to the dentist.
- Behavior: No concerns.
- Activity: Screen/TV time is limited to < 2 hrs/day, gets time outside every day.
PM/SH:
Normal pregnancy and delivery. No surgeries, hospitalizations, or serious illnesses to date.
DEVELOPMENT:
- Gross and fine motor: Can stack 6-8 blocks, stand on one foot, pedal a tricycle, throw a ball overhand, walk up stairs with alternating feet, copy a circle, draw a person with two body parts, dress self (may need some help).
- Cognitive: Knows name, age, sex. Counts to 3 or more.
- Social/Emotional: Joins other children in play. Asks questions. Able to name friends.
- Communication: Others can understand at least 3/4 of what is said. Speaks in 3-4 word sentences. MCHAT in chart.
SOCIAL:
- No smokers in the home.
- No major social stressors at home.
- No safety concerns in the home.
- Daytime child care is with _
- No TB or lead risk factors.
IMMUNIZATIONS:
- Up to date.
OBJECTIVE:
- VITALS: _
- GEN: Normal general appearance. NAD.
- HEAD: NCAT.
- EYES: PERRL, red reflex present bilaterally. Light reflex symmetric. EOMI, with no strabismus.
- ENMT: TMs, nares, and OP normal. MMM. Normal gums, mucosa, palate. Good dentition.
- NECK: Supple, with no masses.
- CV: RRR, no m/r/g.
- LUNGS: CTAB, no w/r/c.
- ABD: Soft, NT/ND, NBS, no masses or organomegaly.
- GU: Normal _male genitalia. Testes descended bilaterally.
- SKIN: WWP. No skin rashes or abnormal lesions.
- MSK: Normal extremities & spine.
- NEURO: Normal muscle strength and tone. No focal deficits.
GROWTH CHART: Following growth curve well in all parameters. BMI at _ percentile.
ASSESSMENT/PLAN:
* Healthy 3yo child
- The family was given a children’s book today (per “Reach Out and Read” program).
- CBC ordered.
- MCHAT was done at 18 and 24 months of age.
- Follow up at 4 years of age, or sooner PRN.
- ER/return precautions discussed.
* Vaccines today:
- Influenza
- None
* Anticipatory guidance (discussed or covered in a handout given to the family)
- Safety: Street/car safety, water safety, toxins (Poison Control number: 800-222-1222), gun safety, helmets and safety equipment.
- Booster seat required by law until 8 yrs old or 4’9”
- Food: Picky eating, fortified skim milk, limiting juice and junk/fast food.
- Discipline: Praising wanted behaviors, time outs, setting limits, routines, offering choices, +expect sharing, limiting screen time.
- Speech: Importance of reading, temporary stuttering
- Dental care and fluoride; dental visits
- Sleep: Nightmares, sleep hygiene
- Hazards of second hand smoke
4 YEARS
 
SUBJECTIVE:
4 yo _ here for well child check. No parental concerns at this time.
REVIEW OF SYSTEMS:
- Diet: No concerns.
- Voiding/stooling: No concerns. + toilet trained (in the day at least).
- Sleeping: No concerns. Has regular bedtime routine.
- Dental: + brushes teeth. Sees the dentist regularly.
- Behavior: No concerns.
- Activity: Screen/TV time is limited to < 2 hrs/day, gets time outside every day.
PM/SH:
Normal pregnancy and delivery. No surgeries, hospitalizations, or serious illnesses to date.
DEVELOPMENT:
- Gross and fine motor: Hops/balances on one foot, can stack 8 blocks, brushes own teeth, dresses self (including buttons), uses scissors, walk up stairs with alternating feet, copies a cross.
- Cognitive: Knows first and last name, age, sex; draws person with at least 3 body parts; names at least 4 colors.
- Social/Emotional: Plays cooperatively, plays board/card games, plays make-believe.
- Communication: Strangers can understand speech, recognizes most letters. Speaks in 3-4 word sentences.
SOCIAL:
- No smokers in the home.
- No major social stressors at home.
- No safety concerns in the home.
- In preschool.
- No TB or lead risk factors.
IMMUNIZATIONS:
- Up to date.
OBJECTIVE:
- VITALS: _
- GEN: Normal general appearance. NAD.
- HEAD: NCAT.
- EYES: PERRL, red reflex present bilaterally. Light reflex symmetric. EOMI, with no strabismus.
- ENMT: TMs, nares, and OP normal. MMM. Normal gums, mucosa, palate. Good dentition.
- NECK: Supple, with no masses.
- CV: RRR, no m/r/g.
- LUNGS: CTAB, no w/r/c.
- ABD: Soft, NT/ND, NBS, no masses or organomegaly.
- GU: Normal _male genitalia. Testes descended bilaterally.
- SKIN: WWP. No skin rashes or abnormal lesions.
- MSK: Normal extremities & spine.
- NEURO: Normal muscle strength and tone. No focal deficits.
GROWTH CHART: Following growth curve well in all parameters. BMI at _ percentile.
LABS/STUDIES:
- Urine dip normal.
- Hearing screen normal.
ASSESSMENT/PLAN:
* Healthy 4 yo child
- The family was given a children’s book today (per “Reach Out and Read” program).
- CBC ordered. No indication for a lipid panel or DM screening.
- MCHAT was done at 18 and 24 months of age.
- Follow up at 5 years of age, or sooner PRN.
- ER/return precautions discussed.
* Vaccines today:
- Kinrix (DTaP #5, IPV #4), MMR #2, Varicella #2, Influenza
* Anticipatory guidance (discussed or covered in a handout given to the family)
- Safety: Street/car safety, strangers, gun safety, helmets and safety equipment.
- Booster seat required by law until 8 yrs old or 4’9”
- Food: Limiting juice and junk/fast food.
- Discipline: Praising wanted behaviors, time outs, setting limits, routines, offering choices.
- Speech: Importance of reading, limiting screen time.
- Dental care and fluoride; dental visits
- Hazards of second hand smoke
5 YEARS
 
SUBJECTIVE:
5 yo _ here for well child check. No parental concerns at this time.
REVIEW OF SYSTEMS:
- Diet: No concerns.
- Fast food, soda, juice intake: _
- Calcium intake: _
- Voiding/stooling: No concerns. + toilet trained (in the day at least).
- Sleeping: No concerns. Has regular bedtime routine.
- Dental: + brushes teeth. Sees the dentist regularly.
- Behavior: No concerns.
- Activity: Screen/TV time is limited to < 2 hrs/day, gets time outside every day.
PM/SH:
Normal pregnancy and delivery. No surgeries, hospitalizations, or serious illnesses to date.
DEVELOPMENT:
- Gross and fine motor: Hops and skips, holds crayon or pencil well, rides a bike, able to tie a knot; copies squares and triangles.
- Cognitive: Draws a person with head, body, and limbs (6+ body parts); knows at least 4 colors; counts to 5 or 10; can explain the use of a ball or shoe.
- Social/Emotional: Plays cooperatively, plays board/card games, plays make-believe, listens and attends.
- Communication: Can speak in full sentences and tell a story, recognizes most letters, prints some letters and numbers.
SOCIAL:
- In kindergarten
- After-school activities:
- No smokers in the home.
- No major social stressors at home.
- No safety concerns in the home.
- No TB or lead risk factors.
IMMUNIZATIONS:
- Up to date.
OBJECTIVE:
- VITALS: _
- GEN: Normal general appearance. NAD.
- HEAD: NCAT.
- EYES: PERRL, red reflex present bilaterally. Light reflex symmetric. EOMI, with no strabismus.
- ENMT: TMs and nares normal. MMM. Normal gums, mucosa, palate, OP. Good dentition.
- NECK: Supple, with no masses.
- CV: RRR, no m/r/g.
- LUNGS: CTAB, no w/r/c.
- ABD: Soft, NT/ND, NBS, no masses or organomegaly.
- GU: Normal _male genitalia. Testes descended bilaterally.
- SKIN: WWP. No skin rashes or abnormal lesions.
- MSK: No deformities. Normal gait. No clubbing, cyanosis, or edema.
- NEURO: Normal muscle strength and tone. No focal deficits.
GROWTH CHART: Following growth curve well in all parameters. BMI at _ percentile.
LABS/STUDIES:
- Urine dip normal.
- Hearing screen normal.
- Snellen testing: _
ASSESSMENT/PLAN:
* Healthy 5 yo child
- The family was given a children’s book today (per “Reach Out and Read” program).
- CBC ordered. No indication for a lipid panel or DM screening.
- Follow up at 6 years of age, or sooner PRN.
- ER/return precautions discussed.
* Vaccines today:
- Influenza
- None
* Anticipatory guidance (discussed or covered in a handout given to the family)
- Safety: Street/car safety, strangers, gun safety, helmets and safety equipment.
- Booster seat required by law until 8 yrs old or 4’9”
- Food and exercise: Limiting juice and junk/fast food, exercise.
- Memorize name, address, and phone number.
- Speech: Importance of reading, limiting screen time.
- Dental care and fluoride; dental visits
- Hazards of second hand smoke
6 YEARS
 
SUBJECTIVE:
6 year old _ here for well child check. No parental or patient concerns at this time.
REVIEW OF SYSTEMS:
- Diet: No concerns.
- Fast food, soda, juice intake: _
- Calcium intake: _
- Voiding/stooling: No concerns.
- Dental: + brushes teeth. Sees the dentist regularly.
- Behavior: No concerns.
PM/SH:
Normal pregnancy and delivery. No surgeries, hospitalizations, or serious illnesses to date.
DEVELOPMENT:
- In _ grade. School is going well.
- Has friends.
- After-school activities: _
- Physical activity (and safety): _
- Screen time: _
- Does chores when asked.
- Knows address and home phone number.
- Can name 4-5 things to eat in 20 seconds.
- Prints letters without problems.
- Dresses self without supervision.
SOCIAL:
- Noteworthy social stressors: _
- No smokers in the home.
- No TB or lead risk factors.
IMMUNIZATIONS:
- Up to date.
OBJECTIVE:
- VITALS: _
- GEN: Normal general appearance. NAD.
- HEAD: NCAT.
- EYES: PERRL, red reflex present bilaterally. Light reflex symmetric. EOMI.
- ENMT: TMs and nares normal. MMM. Normal gums, mucosa, palate, OP. Good dentition.
- NECK: Supple, with no masses.
- CV: RRR, no m/r/g.
- LUNGS: CTAB, no w/r/c.
- ABD: Soft, NT/ND, NBS, no masses or organomegaly.
- GU: Normal _male genitalia. Testes descended bilaterally.
- SKIN: WWP. No skin rashes or abnormal lesions.
- MSK: No deformities. Normal gait. No clubbing, cyanosis, or edema.
- NEURO: Normal muscle strength and tone. No focal deficits.
GROWTH CHART: Following growth curve well in all parameters. BMI at _ percentile.
LABS/STUDIES:
- Urine dip normal.
- Hearing screen normal.
- Snellen testing: _
ASSESSMENT/PLAN:
* Healthy 6 yo child
- CBC ordered. No indication for a lipid panel or DM screening.
- Follow up at 7 years of age, or sooner PRN.
- ER/return precautions discussed.
* Vaccines today:
- Influenza
- None
* Anticipatory guidance (discussed or covered in a handout given to the family)
- Safety: Street safety, strangers, gun safety, helmets and safety equipment.
- Booster seat required by law until 8 yrs old or 4’9”
- Food and exercise: Limiting juice and junk/fast food, exercise.
- Memorize name, address, and phone number.
- School: Communicate with teachers, discuss peer pressure and bullying, internet safety.
- Speech: Importance of reading, limiting screen time.
- Dental care and fluoride; dental visits
- Hazards of second hand smoke
7 YEARS
 
SUBJECTIVE:
7 yo _ here for well child check. No parental or patient concerns at this time.
REVIEW OF SYSTEMS:
- Diet: No concerns.
- Fast food, soda, juice intake: _
- Calcium intake: _
- Voiding/stooling: No concerns.
- Dental: + brushes teeth. Sees the dentist regularly.
- Behavior: No concerns.
PM/SH:
Normal pregnancy and delivery. No surgeries, hospitalizations, or serious illnesses to date.
DEVELOPMENT:
- In _ grade. School is going well.
- Has friends.
- After-school activities: _
- Physical activity (and safety): _
- Screen time: _
- Does chores when asked.
- Knows address and home phone number.
- Prints letters without problems.
SOCIAL:
- Noteworthy social stressors: _
- No smokers in the home.
- No TB or lead risk factors.
IMMUNIZATIONS:
- Up to date.
OBJECTIVE:
- VITALS: _
- GEN: Normal general appearance. NAD.
- HEAD: NCAT.
- EYES: PERRL, red reflex present bilaterally. Light reflex symmetric. EOMI.
- ENMT: TMs and nares normal. MMM. Normal gums, mucosa, palate, OP. Good dentition.
- NECK: Supple, with no masses.
- CV: RRR, no m/r/g.
- LUNGS: CTAB, no w/r/c.
- ABD: Soft, NT/ND, NBS, no masses or organomegaly.
- GU: Normal _male genitalia. Testes descended bilaterally.
- SKIN: WWP. No skin rashes or abnormal lesions.
- MSK: No deformities. Normal gait. No clubbing, cyanosis, or edema.
- NEURO: Normal muscle strength and tone. No focal deficits.
GROWTH CHART: Following growth curve well in all parameters. BMI at _ percentile.
LABS/STUDIES:
- Urine dip normal.
- Hearing screen normal.
- Snellen testing: _
ASSESSMENT/PLAN:
* Healthy 7 yo child
- CBC ordered. No indication for a lipid panel or DM screening.
- Follow up at 8 years of age, or sooner PRN.
- ER/return precautions discussed.
* Vaccines today:
- Influenza
- None
* Anticipatory guidance (discussed or covered in a handout given to the family)
- Safety: Street safety, strangers, gun safety, helmets and safety equipment.
- Booster seat required by law until 8 yrs old or 4’9”
- Food and exercise: Limiting juice and junk/fast food, exercise.
- Memorize name, address, and phone number.
- School: Communicate with teachers, discuss peer pressure and bullying, internet safety.
- Speech: Importance of reading, limiting screen time.
- Dental care and fluoride; dental visits
- Hazards of second hand smoke
8-11 YEARS
 
SUBJECTIVE:
_ here for well child check. No parental or patient concerns at this time.
REVIEW OF SYSTEMS:
- Diet: No concerns.
- Fast food, soda, juice intake: _
- Calcium intake: _
- Dental: + brushes teeth. Sees the dentist regularly.
- Sleep concerns (duration, snoring, bedtime): None.
- Elimination concerns (including menses in females): _
PM/SH:
Normal pregnancy and delivery. No surgeries, hospitalizations, or serious illnesses to date.
DEVELOPMENT:
- In _ grade. School is going well. No parental or teacher concerns about behavior.
- Friends/hobbies (i.e. after school activities): _
- Physical activity (and safety): _
- Screen time: _
SOCIAL:
- Noteworthy social stressors: _
- No smokers in the home.
- No TB or lead risk factors.
IMMUNIZATIONS:
- Up to date.
OBJECTIVE:
- VITALS: _
- WEIGHT: BMI _
- GEN: Normal general appearance. NAD.
- HEAD: NCAT.
- EYES: PERRL, red reflex present bilaterally. Light reflex symmetric. EOMI.
- ENMT: TMs and nares normal. MMM. Normal gums, mucosa, palate, OP. Good dentition.
- NECK: Supple, with no masses.
- CV: RRR, no m/r/g.
- LUNGS: CTAB, no w/r/c.
- ABD: Soft, NT/ND, NBS, no masses or organomegaly.
- GU: Normal genitalia, Tanner stage _
- SKIN: WWP. No skin rashes or abnormal lesions.
- MSK: No deformities or signs of scoliosis. Normal gait. No clubbing, cyanosis, or edema.
- NEURO: Normal muscle strength and tone. No focal deficits.
LABS/STUDIES:
- Urine dip normal.
- Hearing screen normal.
- Snellen testing: _
ASSESSMENT/PLAN:
* Healthy _ yo child
- CBC ordered. No indication for a lipid panel or DM screening.
- Follow in one year, or sooner PRN.
- ER/return precautions discussed.
* Vaccines today:
- Influenza, HPV (0, 1-2, and 6 months, starting at age 9), Tdap (11-12), Meningococcal (11-12)
* Anticipatory guidance (discussed or covered in a handout given to the family)
- Puberty
- Peer pressure, bullying, communication with teachers, violence prevention
- Seat belts, helmets and safety gear, sunscreen
- Internet safety, limiting screen time
- Appropriate discipline for age
- Healthy food, exercise, good dental hygiene
- Eliminating guns from the home, or locking bullets separately
- Hazards of second hand smoke
ADOLESCENT (12 yrs and older)
 
SUBJECTIVE:
_ here for well child check. No parental or patient concerns at this time.
RISK ASSESSMENT (non-confidential):
- Has never fainted before.
- No h/o cough, chest pain, or shortness of breath with exercise.
- Has never had a significant head injury.
- No family history of someone dying suddenly while exercising.
- No family history of MI or stroke before age 55.
RISK ASSESSMENT (confidential):
- Home: Safe, peaceful home environment. Family members all get along, more or less.
- Education/Employment: School is going _. No problems with safety or bullying at school.
- Eating: No concerns about body appearance. Getting sufficient calcium in diet (at least 4 servings per day). No dietary restrictions.
- Activities: Enjoys hanging out with friends. Screen time _. Is involved in _
- Drugs: No history of tobacco, EtOH, or drug use. No friends are using these substances.
- Safety: No history of violent relationships at home or elsewhere.
- Sex: Prefers _. Has not been sexually active (oral or genital) yet.
- Suicidality/Mental Health: No concerns. No history of physical or sexual abuse. Sleeps well at night.
PM/SH:
Normal pregnancy and delivery. No surgeries, hospitalizations, or serious illnesses to date.
OB/GYN HX:
Menses started at age _, and is regular.
SOCIAL:
- No smokers in the home.
- No TB or lead risk factors.
- Plans after high school: _
IMMUNIZATIONS:
- Up to date.
OBJECTIVE:
- VITALS: _
- WEIGHT: BMI _
- GEN: Normal general appearance. NAD.
- HEAD: NCAT.
- EYES: PERRL, red reflex present bilaterally. Light reflex symmetric. EOMI.
- ENMT: TMs and nares normal. MMM. Normal gums, mucosa, palate, OP. Good dentition.
- NECK: Supple, with no masses.
- CV: RRR, no m/r/g.
- LUNGS: CTAB, no w/r/c.
- ABD: Soft, NT/ND, NBS, no masses or organomegaly.
- GU: Normal genitalia, Tanner stage _
- SKIN: WWP. No skin rashes or abnormal lesions.
- MSK: No deformities or signs of scoliosis. Normal gait. No clubbing, cyanosis, or edema.
- NEURO: Normal muscle strength and tone. No focal deficits.
LABS/STUDIES:
- Urine dip normal.
- Hearing screen normal.
- Snellen testing: _
ASSESSMENT/PLAN:
* Healthy _ yo adolescent
- CBC ordered. No indication for a lipid panel or DM screening.
- Follow in one year, or sooner PRN.
- ER/return precautions discussed.
* Vaccines today:
- Influenza, HPV (0, 1-2, and 6 months, starting at age 9), Tdap (11-12), Meningococcal (11-12)
* Anticipatory guidance (discussed or covered in a handout given to the family)
- Confidentiality of visit documentation.
- Puberty, sex, abstinence, safe dating.
- Avoiding tobacco, drugs, alcohol; and never getting into a car with someone under the influence.
- Dealing with stress.
- Discipline and role models.
- Seat belts, helmets and safety gear, sunscreen
- Internet safety, limiting screen time
- Importance of daily exercise.
- Obesity prevention and adequate calcium.
- Good dental hygiene.
- Eliminating guns from the home, or locking bullets separately
Last modified on %PM, %949 %23 %2015 %14:%Sep
  • All templates, "autotexts", procedure notes, and other documents on these pages are intended as examples only.  Your documentation in the medical record should always reflect precisely your specific interaction with an individual patient.  Merely copying and pasting a prewritten note into a patient's chart is unethical, unsafe, and possibly fradulent.