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Health Maintenance Visit – Pediatrics
Mar 31, 2010
•
Mark Morgan
categories:
Complete Note
Pediatrics
See also the updated version at this page
Subjective/History
1 week
2 month
4 month
6 month
9 month
12 month
15 month
2 year
3 year
4 year
5 year
6-10 year
11-14 year
15-18 year
Objective/Examination
newborn male
newborn female
less than 1 year old male
less than 1 year old female
1-4 year old male
1-4 year old female
greater than 4 year old male
greater than 4 year old female
Assessment/Plan
1 week
2 month
4 month
6 month
9 month
12 month
15 month
2 year
3 year
4 year
5 year
6-10 year
11-14 year
15-18 year
#1 Normal growth and development. Injury prevention and health promotion issues discussed. Age specific guidance: infant should sleep on back, pets (keep separated from child), use of car restraints, do not leave near water or where child can fall, assure water heater temp. set less than 120 degrees and test fire alarms.
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No immunizations/Hepatitis B given today. Side effects, risks, and benefits of immunizations discussed.
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Return to clinic at 2 months of age, or sooner if concerns arise. Approved for all routine preventive medicine services, including immunizations. Abuse/neglect, functional status, nutrition and pain assessed and no further evaluation is needed.
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#1 Normal growth and development. Age specific guidance: infant should sleep on back, use car restraints, do not leave the child near water or where the child can fall, do not use walkers or small toys and burn prevention reviewed.
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Immunizations today: HBV-Hib, DTaP, and IPV (Hepatitis B-Haemophilus influenza, Diphtheria-Tetanus-acellular Pertussis and polio), PCV7 (Pneumococcal), Rota. Side effects, risks, and benefits of immunizations discussed.
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Return to clinic at 4 months of age, or sooner if concerns arise. Approved for all routine preventive medicine services, including immunizations. Abuse/neglect, functional status, nutrition and pain assessed and no further evaluation is needed.
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#1 Normal growth and development. Age specific guidance: use car restraints, do not leave near water or where the child can fall, do not use walkers or small toys, avoidance of plastic's suffocation and burn prevention reviewed. A/B Otic drops prescription and discussion about how to use as needed.
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Immunizations today: Hib, DTaP, and IPV (Hepatitis B- Haemophilus influenza, Diphtheria-Tetanus, acellular Pertussis and polio), PCV7 (Pneumococcal), Rotavirus. Side effects, risks, and benefits of immunizations discussed.
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Return to clinic at 6 months of age, or sooner if concerns arise. Approved for all routine preventive medicine services, including immunizations. Abuse/neglect, functional status, nutrition and pain assessed and no further evaluation is needed.
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#1 Health Maintenance-Normal Growth and Development. Age specific guidance: use of car restraints, supervise around water or where the child can fall, use gates to block stairway, be careful of cords and plants, do not use walkers or allow with small objects, burn prevention reviewed.
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Side effects, risks and benefits of immunizations. Immunizations today: DTaP (Diphtheria-Tetanus-acellular Pertussis)/HBV (hepatitis)/PCV7 (Pneumococcal)/ROTA (Rotavirus)
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Return appointment: age nine months/age twelve months/age fifteen months or sooner if needed.
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#1 Normal growth and development. Injury prevention and health promotion issues discussed.
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No immunizations given today/Immunizations given today. Side effects, risks, and benefits of immunizations discussed.
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Return to clinic at 12 months of age, or sooner if concerns arise. Approved for all routine preventive medicine services, including immunizations. Abuse/neglect, functional status, nutrition and pain assessed and no further evaluation is needed.
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#1 Normal growth and development. Injury prevention and health promotion issues discussed.
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No immunizations given today/Immunizations given today. Side effects, risks, and benefits of immunizations discussed.
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Return to clinic at 15 months of age, or sooner if concerns arise. Approved for all routine preventive medicine services, including immunizations. Abuse/neglect, functional status, nutrition and pain assessed and no further evaluation is needed.
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#1 Health Maintenance-Normal Growth and Development. Age specific guidance: choking, use of gates, caution around open water, falling, sunscreen if summer, smoke detectors, smoke free environment, lower crib mattress, check window guards, supervise near dogs and lawnmowers and streets and driveways, burn prevention, and tantrum information reviewed. Recommended to eat meals as family, allow toddler to feed self and drink from cup not bottle, 2 snacks low in sugar daily, avoid choke foods, don't put toddler to bed with bottle, brush teeth daily, fluoride discussed. Give individual attention, limit but enforce rules, allow no harm to self or things or others, delay toilet training.
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Poison prevention discussed -- Keep potential poisons out of sight and out of reach. Always reengage child-resistant closures immediately after using a pharmaceutical or consumer product. Never transfer a substance from its original container to an alternate one. Safely dispose of all unused medication and medication that is no longer needed. Do not refer to medicines as candy. Post the poison control center number near the telephone. The universal telephone number in the United States is 800-222-1222. Calls are routed to the local poison control center. Tuberculosis Risk (Close contact with person with TB, live in area where TB is common, recent immigrant?): No/Yes, testing recommended
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Side effects, risks and benefits of immunizations discussed. Immunizations today: DTaP/Hib/PCV7/Influenza vaccine/HAV
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Return appointment: age two years/age 18 month visit with doctor/age 18 month visit with nurse for immunizations or sooner if needed.
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#1 Normal growth and development. Age specific guidance: Burn prevention, care near streets, caution around open water, use of car seats, transition from crib to bed, toilet training, night terrors and tantrum information reviewed.
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No immunizations given today/Influenza/Hepatitis A/Side effects, risks, and benefits of immunizations discussed.
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Return to clinic at 3 years of age, or sooner if concerns arise. Approved for all routine preventive medicine services, including immunizations. Testing is/not indicated for TB (exposure to patient with TB, recent immigrant, area with high TB prevalence). Testing is/not indicated for lead (house older than 1950). Abuse/neglect, functional status, nutrition and pain assessed and no further evaluation is needed.
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#1 Normal growth and development. Age specific guidance: Burn prevention, care near streets, caution around open water, use of car seats, transition from crib to bed, use of bike helmet, toilet training, night terrors and tantrum information reviewed.
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No immunizations given today/Immunizations given today/MMR (Measles-Mumps-Rubella)/Side effects, risks, and benefits of immunizations discussed.
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Vision screening: assessed/not assessed/child uncooperative. Hearing screening: assessed/not assessed/child uncooperative. Testing is/not indicated for TB (exposure to patient with TB, recent immigrant, area with high TB prevalence). Testing is/not indicated for lead (house older than 1950).
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Return to clinic at 5 years of age, or sooner if concerns arise. Approved for all routine preventive medicine services, including immunizations. Abuse/neglect, functional status, nutrition and pain assessed and no further evaluation is needed.
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#1 Normal growth and development. Injury prevention and health promotion issues discussed.
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No immunizations given today/Immunizations given today.. Side effects, risks, and benefits of immunizations discussed.
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Return to clinic in two years or sooner if concerns arise. Approved for all routine preventive medicine services, including immunizations. Abuse/neglect, functional status, nutrition and pain assessed and no further evaluation is needed.
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#1 Health Maintenance-Normal Growth and Development. Age specific guidance: Burn prevention (matches), care near streets, caution around open water, use of seatbelt information reviewed, self-esteem issues, limit television time, use of helmets when riding bike or scooter
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Immunizations today: None/DTaP/MMRV/IPV/Flu/Hep A. Side effects, risks and benefits of immunizations.
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Vision screening: assessed/not assessed/child uncooperative. Hearing screening: assessed/not assessed/child uncooperative. Return appointment: age 7 yrs/age 9 yrs or sooner if needed.
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#1 Normal growth and development. Injury prevention and health promotion issues discussed.
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No immunizations given today/Immunizations given today. Side effects, risks, and benefits of immunizations discussed.
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Return to clinic in 2 years or sooner if concerns arise. Approved for all routine preventive medicine services, including immunizations. Abuse/neglect, functional status, nutrition and pain assessed and no further evaluation is needed.
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#1 Normal growth and development. Injury prevention and health promotion issues discussed.
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Immunizations given/No immunizations given today. Side effects, risks, and benefits of immunizations discussed.
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Return to clinic in 2 years or sooner if concerns arise. Approved for all routine preventive medicine services, including immunizations. Abuse/neglect, functional status, nutrition and pain assessed and no further evaluation is needed.
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#1 Normal growth and development. Injury prevention and health promotion issues discussed.
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Immunizations given. Side effects, risks, and benefits of immunizations discussed/No immunizations given today.
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Return to clinic in 2 years or sooner if concerns arise. Approved for all routine preventive medicine services, including immunizations. Abuse/neglect, functional status, nutrition and pain assessed and no further evaluation is needed.
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