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Primary Care Physician
10-15 minutes

Pediatric Health Examination Template

The s10.ai well-child check-up template is expertly crafted for general practitioners and pediatricians to efficiently document routine pediatric visits. This comprehensive template encompasses sections for developmental history, medical history, physical examination, developmental and behavioral assessment, preventive health recommendations, immunizations, follow-up, and patient education. By ensuring all critical aspects of a child's health and development are meticulously reviewed and recorded, this template enhances the quality of pediatric care. Perfect for integration with s10.ai, it streamlines the documentation process, empowering clinicians to deliver superior healthcare. Keywords: well-child check-up, pediatric visit documentation, general practitioner, medical documentation template.

2,319 uses
4.3/5.0
J
Jordan Patel
Template Structure

Organized sections for comprehensive clinical documentation

Patient Name: [Child’s Name]
Date of Birth: [DOB]
Date of Consultation: [Date]
Medical Record Number: [MRN]
Routine Pediatric Examination Documentation
Parent/Guardian Present:
- Name: [Parent/Guardian’s Name] (enter the name of the parent or guardian present)
Developmental History:
- Milestones: [e.g., Walking independently, speaking in sentences] (describe the child's developmental milestones)
- School/Daycare: [e.g., Attending preschool, social interactions] (provide information about school or daycare attendance and social interactions)
Medical History:
- Previous Illnesses: [e.g., History of asthma, chickenpox] (list any previous illnesses)
- Chronic Conditions: [e.g., No chronic conditions reported] (mention any chronic conditions)
- Allergies: [e.g., No known drug or food allergies] (record any known allergies)
- Immunizations: [e.g., Up-to-date with vaccinations as per schedule] (note immunization status)
- Medications: [e.g., None currently prescribed] (list any current medications)
Physical Examination:
- General Appearance: [e.g., Well-nourished, active, and alert] (describe the general appearance of the child)
- Growth Measurements:
- Weight: [e.g., 22 kg] (record weight)
- Height: [e.g., 110 cm] (record height)
- Head Circumference: [e.g., 50 cm, if relevant] (record head circumference if relevant)
- Vital Signs:
- Temperature: [e.g., 36.8°C] (record temperature)
- Heart Rate: [e.g., 110 bpm] (record heart rate)
- Respiratory Rate: [e.g., 20 bpm] (record respiratory rate)
- Blood Pressure: [e.g., 90/60 mmHg, if age-appropriate] (record blood pressure if appropriate)
- Systemic Examination:
- Head and Neck: [e.g., Normal, no signs of enlarged lymph nodes] (describe findings)
- Chest: [e.g., Clear breath sounds, no wheezing] (describe findings)
- Abdomen: [e.g., Soft, non-tender, normal bowel sounds] (describe findings)
- Musculoskeletal: [e.g., Normal range of motion, no deformities] (describe findings)
Developmental and Behavioral Assessment:
- Cognitive Development: [e.g., Appropriate for age, follows instructions] (describe cognitive development)
- Social and Emotional Development: [e.g., Engages well with peers, appropriate emotional responses] (describe social and emotional development)
- Behavioral Concerns: [e.g., No significant behavioral issues reported] (mention any behavioral concerns)
Preventive Health Recommendations:
- Nutrition: [e.g., Balanced diet with fruits, vegetables, and whole grains; limit sugary snacks] (provide nutritional recommendations)
- Physical Activity: [e.g., Encourage at least 1 hour of active play daily] (recommend physical activity)
- Sleep: [e.g., Recommended 10-12 hours of sleep per night] (provide sleep recommendations)
- Dental Care: [e.g., Regular brushing, dental check-ups every 6 months] (give dental care advice)
Immunizations:
- Vaccinations Administered: [e.g., DTP, MMR, Varicella, if any] (list any vaccinations given during the visit)
- Next Due Vaccines: [e.g., HPV series, scheduled for [Date]] (note the next due vaccines and their scheduled date)
Follow-Up and Next Steps:
- Next Well-Child Visit: [e.g., Scheduled for [Date], typically at [Age]] (schedule the next visit)
- Referral: [e.g., No referrals needed at this time] (mention any referrals if needed)
- Additional Testing: [e.g., No additional tests required] (list any additional tests if required)
Patient and Parent/Guardian Education:
- Discussed: Importance of regular physical activity, healthy diet, and routine dental care (detail education provided)
- Materials Provided: [e.g., Handouts on nutrition and physical activity] (list any materials given)
Parent/Guardian Understanding:
- Confirmed: Yes, parent/guardian demonstrated understanding of the health recommendations and follow-up plan.
Signature:
[Provider’s Name]
[Provider’s Title]
[Provider’s Contact Information]
Date: [Date of Documentation]
Sample Clinical Note

Example of completed documentation using this template

Patient Name: Emily Johnson  
Date of Birth: 01/15/2018  
Date of Consultation: 10/05/2023  
Medical Record Number: 123456  
Well-Child Check-Up Documentation  
Parent/Guardian Present:  
- Name: Sarah Johnson  
Developmental History:  
- Milestones: Walking independently, speaking in sentences  
- School/Daycare: Attending preschool, social interactions are positive  
Medical History:  
- Previous Illnesses: History of chickenpox  
- Chronic Conditions: No chronic conditions reported  
- Allergies: No known drug or food allergies  
- Immunizations: Up-to-date with vaccinations as per schedule  
- Medications: None currently prescribed  
Physical Examination:  
- General Appearance: Well-nourished, active, and alert  
- Growth Measurements:  
  - Weight: 22 kg  
  - Height: 110 cm  
  - Head Circumference: 50 cm  
- Vital Signs:  
  - Temperature: 36.8°C  
  - Heart Rate: 110 bpm  
  - Respiratory Rate: 20 bpm  
  - Blood Pressure: 90/60 mmHg  
- Systemic Examination:  
  - Head and Neck: Normal, no signs of enlarged lymph nodes  
  - Chest: Clear breath sounds, no wheezing  
  - Abdomen: Soft, non-tender, normal bowel sounds  
  - Musculoskeletal: Normal range of motion, no deformities  
Developmental and Behavioral Assessment:  
- Cognitive Development: Appropriate for age, follows instructions  
- Social and Emotional Development: Engages well with peers, appropriate emotional responses  
- Behavioral Concerns: No significant behavioral issues reported  
Preventive Health Recommendations:  
- Nutrition: Balanced diet with fruits, vegetables, and whole grains; limit sugary snacks  
- Physical Activity: Encourage at least 1 hour of active play daily  
- Sleep: Recommended 10-12 hours of sleep per night  
- Dental Care: Regular brushing, dental check-ups every 6 months  
Immunizations:  
- Vaccinations Administered: DTP, MMR, Varicella  
- Next Due Vaccines: HPV series, scheduled for 01/15/2028  
Follow-Up and Next Steps:  
- Next Well-Child Visit: Scheduled for 01/15/2024, typically at 6 years  
- Referral: No referrals needed at this time  
- Additional Testing: No additional tests required  
Patient and Parent/Guardian Education:  
- Discussed: Importance of regular physical activity, healthy diet, and routine dental care  
- Materials Provided: Handouts on nutrition and physical activity  
Parent/Guardian Understanding:  
- Confirmed: Yes, parent/guardian demonstrated understanding of the health recommendations and follow-up plan.  
Signature:  
Dr. Thomas Kelly  
General Practitioner  
555-123-4567  
Date: 10/05/2023
Clinical Benefits

Key advantages of using this template in clinical practice

  • The Well-Child Check-Up Documentation template is an essential tool for healthcare providers to ensure comprehensive pediatric care. This template facilitates detailed recording of a child's developmental history, medical history, and physical examination findings, including growth measurements and vital signs. It also supports a thorough developmental and behavioral assessment, offering insights into cognitive, social, and emotional development. With sections dedicated to preventive health recommendations, immunization status, and follow-up plans, this template aids in delivering holistic care and promoting healthy growth and development. Clinicians can efficiently document and track a child's health progress, ensuring timely interventions and parental education. By adopting this template, healthcare professionals can enhance patient care quality, streamline documentation processes, and improve communication with parents or guardians.
Frequently Asked Questions

Common questions about this template and its usage

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