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Advanced Practice Registered Nurse
10-15 minutes

Pediatric Wellness Check

The Well Child Visit template from s10.ai is expertly crafted for Nurse Practitioners performing routine pediatric examinations. This template offers a detailed structure for recording a child's health status, addressing parental concerns, and tracking developmental milestones. It features dedicated sections for history of present illness, physical assessment, and plan/recommendations, ensuring comprehensive documentation of each visit. Particularly beneficial for capturing in-depth information on nutrition, sleep, safety, and health risks, this template is optimized for integration with s10.ai's AI medical scribe, streamlining the documentation process and elevating the quality of pediatric care.

2,303 uses
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Dr. Emily Thompson
Template Structure

Organized sections for comprehensive clinical documentation

CHIEF COMPLAINT
[Age of routine pediatric examination]
HISTORY OF PRESENT ILLNESS
(Under the parental concerns, please place any concerns that are voiced by the parent regardless of when they are brought up during the visit. However, you should also fill in the remainder of the headings such as sleep, dental, etc. Do not ignore the other headings if the parents have concerns because you need to document the parental concerns as well as all of the well visit questions. Use professional medical language here, use medical terms where possible. Be detailed in this section. DO NOT use quotes in this section. Do not list the same piece of information twice in this section, only list it once where you feel it best fits.)
(Do not put any recommendations or plans in this part, put that below under PLAN/RECOMMENDATIONS)
[Patient demographic information - age, sex, who they are here with today for the visit. Also include any historical information which I say in the beginning of the visit, prior to starting the visit discussion with the parent or patient]
Parental Concerns: [Parental concerns or questions] (Even if the parent says they have no concerns or questions, if they bring up anything that does not fit into one of the categories below under history of present illness, put all of that information here under parent concerns. Put EVERYTHING that the parent or patient brings up during the visit here, regardless of where in the visit or conversation it took place. Make this section in paragraph form and make each concern a new paragraph. Be detailed in this section in particular. You should include everything that we talk about here regarding history)
Nutrition/Elimination: [Eating habits] [Elimination habits]
Dental: [Dental health]
Sleep: [Sleep location] [Sleep quality]
Menstrual status: [are they premenarcheal or has their period started, is it regular/heavy/light/painful, what age did it start, etc.] (Do NOT comment on this if they are under 8 years of age or if they are a male)
Development/Behavior: [SWYC Developmental screening tool used and score] [Developmental concerns]
Safety: [Car safety measures] [Home safety measures]
Health Risks: [second hand smoke exposure, drug use, sexual activity, any anxiety or depression.] (Always comment on anxiety or depression here unless they are under 4 years of age, then do NOT comment on anxiety, depression, or sexual activity as that is not appropriate for that age group.) Do not comment about sexual activity or drug use if the child is under 10 years of age. If I ask about kissing, dating, or holding hands, and they say no, simply note no sexual activity under this heading, do not specifically say they are not kissing, dating or holding hands.)
Childcare/School: [Childcare/school information]
[please put any additional concerns or questions that parents/patient have here that do not fit under any of the headings above. Make sure to include all concerns that parents/patients bring up and document them in detail]
(Always output: "REVIEW OF SYMPTOMS")
(Always output: "All other systems negative except as documented in the HPI.")
(Always output the following three NEVER OMIT THIS: "")
PHYSICAL ASSESSMENT
(make note of anything that is a positive or a negative here. Otherwise, fill it in with normals as per the following using proper and professional medical terms, not slang terms:)
GENERAL - [General appearance and nutrition status]
HEAD – [Head examination findings]
EYES - Conjunctiva and lids: [Conjunctiva and lids findings] Pupils and irises: [Pupils and irises findings] [Corneal light reflex findings]
EARS, NOSE, MOUTH AND THROAT - External inspection of ears and nose: [External ear and nose findings] Otoscopic examination: [Tympanic membrane findings] [Canal findings] Oropharynx: [Oropharynx findings]
NECK - Examination of neck: [Neck examination findings]
PULMONARY - Respiratory effort: [Respiratory rate, rhythm, and work of breathing findings] Auscultation of lungs: [Lung auscultation findings]
CARDIOVASCULAR - Auscultation of heart: [Heart rate, rhythm, and sounds findings]
ABDOMEN - Examination of abdomen: [Bowel sounds, tenderness, and masses findings] Examination of liver and spleen: [Liver and spleen findings]
LYMPHATIC - Palpation of lymph nodes in neck: [Cervical and supraclavicular lymph node findings]
MUSCULOSKELETAL - [Muscle tone, development, and strength findings including ortolani and barlow if under 6 month of age. Use the words ortolani and barlow if I say no clicks or clunks. DO NOT comment on ortolani or barlow if older than 6 months of age]
SKIN - Skin and subcutaneous tissue: [Skin and subcutaneous tissue findings]
NEUROLOGIC - Sensation: [Sensation findings] [Mental status findings]
GENITOURINARY - [Genitourinary examination findings]
[Vision and hearing screening results and documentation if any are mentioned. If these are not mentioned, do not include anything here]
ASSESSMENT
1. [Age] routine pediatric examination
2. [Additional diagnoses, number each diagnosis in sequence]
PLAN/RECOMMENDATIONS
1. [Next routine visit age. Over the age of 3, there is a routine visit every year. under the age of three routine visits are as follows: newborn, 1 month, 2 months, 4 months, 6 months, 9 months, 12 months, 15 months, 18 months, 2 years, 2 1/2 years of age.]
2. Immunizations: [Immunization documentation, also include if parents declined any vaccination that was offered. If immunizations were given, please also state " Discussed required vaccines as indicated by the CDC immunization schedule. Immunizations given today as above after informed consent discussion during which all parent's questions were answered, concerns were reviewed at length, and I have personally provided face to face counseling on all vaccine components." Do not state this if immunizations were not given or were deferred by parent today]
[Additional plans/discussions, each one with the next number in the sequence.] (Be descriptive here and outline what was discussed, advised and what education was provided to the patient. Note if any reasons for follow up were discussed.)
Counseling: [Any topics discussed during counseling or any recommendations given]
[Return to care instructions and parent understanding of plan documentation. Do not mention that anticipatory guidance handouts were given because I do not use these.]
(Never come up with your own patient details, assessment, plan, interventions, evaluation, and plan for continuing care - use only the transcript, contextual notes or clinical note as a reference for the information included in your note. also, please do not use the word obesity anywhere in any notes, rather, state the bmi percentile. For example, if bmi is greater than 95th or 99th percentile, use that term instead of obesity which can be perceived as offensive by some parents/children. DO NOT USE QUOTES anywhere in this document. ALWAYS add verbatim any test that is wrapped with " " word for word. Use professional terms in this document, for example use the term stool diaper, not the term poopy diaper)
Sample Clinical Note

Example of completed documentation using this template

CHIEF COMPLAINT  
5-year-old routine pediatric examination
HISTORY OF PRESENT ILLNESS  
Patient is a 5-year-old girl attending a standard well child check-up with her mother. She has a history of asthma, which is effectively managed with her current treatment.
Parental Concerns: The mother is worried about the child's selective eating patterns and occasional nightmares. She also noted increased irritability in the child.
Nutrition/Elimination: The child has a restricted diet, favoring only specific foods, and experiences regular bowel movements.
Dental: No dental problems reported, and regular dental visits are maintained.
Sleep: Sleeps independently, but has occasional nightmares.
Menstrual status: Not applicable.
Development/Behavior: SWYC Developmental screening tool applied, results within normal range. No developmental issues observed.
Safety: Car seat is used correctly. Home safety precautions are in place.
Health Risks: No exposure to second-hand smoke. No signs of anxiety or depression.
Childcare/School: Attends kindergarten, no problems reported.
Additional Concerns: None reported.
REVIEW OF SYMPTOMS  
All other systems negative except as documented in the HPI.
PHYSICAL ASSESSMENT  
GENERAL - Well-nourished, active child.  
HEAD – Normocephalic, atraumatic.  
EYES - Conjunctiva and lids clear, pupils equal, round, reactive to light and accommodation, corneal light reflex normal.  
EARS, NOSE, MOUTH AND THROAT - Ears and nose normal on external inspection, tympanic membranes intact, oropharynx clear.  
NECK - Supple, no lymphadenopathy.  
PULMONARY - Normal respiratory effort, clear to auscultation bilaterally.  
CARDIOVASCULAR - Regular rate and rhythm, no murmurs.  
ABDOMEN - Soft, non-tender, normal bowel sounds, no hepatosplenomegaly.  
LYMPHATIC - No cervical or supraclavicular lymphadenopathy.  
MUSCULOSKELETAL - Normal muscle tone and strength.  
SKIN - No rashes or lesions.  
NEUROLOGIC - Alert, oriented, normal sensation and mental status.  
GENITOURINARY - Normal external genitalia.
ASSESSMENT  
1. 5-year-old routine pediatric examination  
2. Asthma, effectively managed
PLAN/RECOMMENDATIONS  
1. Schedule next well visit at 6 years of age.  
2. Immunizations: Discussed necessary vaccines as per CDC immunization schedule. Vaccines administered today following informed consent discussion, during which all parental questions were addressed, concerns were thoroughly reviewed, and I personally provided face-to-face counseling on all vaccine components.  
3. Recommended a balanced diet to address selective eating habits.  
4. Discussed sleep hygiene to assist with nightmares.
Counseling: Emphasized the importance of balanced nutrition and regular physical activity.
Return to care instructions and parent understanding of plan documented.
Clinical Benefits

Key advantages of using this template in clinical practice

  • This comprehensive clinical template for well child checks is meticulously designed to streamline pediatric assessments, ensuring thorough documentation of parental concerns and child health metrics. Clinicians can efficiently capture detailed history of present illness, covering essential areas such as nutrition, dental health, sleep patterns, developmental milestones, and safety measures. The template also facilitates the documentation of health risks, childcare, and school information, providing a holistic view of the child's well-being. With a structured physical assessment section, healthcare providers can accurately record findings across multiple systems, from general appearance to neurologic evaluations. The template's assessment and plan/recommendations sections guide clinicians in outlining follow-up care, immunization schedules, and counseling topics, promoting proactive health management. By adopting this template, clinicians can enhance the quality of pediatric care, ensuring all critical aspects of a child's health are addressed and documented with precision.
Frequently Asked Questions

Common questions about this template and its usage

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