WC – Yr 3

.
[checkbox name="historian" value=" new patient|existing patient||parent present|sibling/another family member present|social services/group home/foster family present|chaperon/MA present during visit||interpretation provided by family member/SO|interpretation provided by MA|"][textarea cols=50 rows=3]
PMH/SPECIAL NEEDS/PARENTAL CONCERNS: [checkbox name="special" value="weight concerns|asthma|allergies|anemia||none identified|"][textarea cols=50 rows=2]
INTERVAL HISTORY: [checkbox name="interval" value="sick contact|travel||ER/UC visit|illness|injury|hospitalization/surgery/procedure||diagnostic/laboratory studies|specialty consults||new/changed medications|ABX use||no changes since last visit|"][textarea cols=50 rows=2]
MEDICATIONS: [checkbox name="medications" value="Rx|OTC||taking as prescribed|not taking as prescribed||none reported|"][textarea cols=50 rows=2]
SCREENING: [checkbox name="screen" value="lead|TB||completed today & discussed with parent||consider formal referral|negative|deferred|"][textarea cols=50 rows=2]
GROWTH & DEVELOPMENT: age-specific topics discussed, milestones assessed, and/or handout provided, [checkbox name="development" value="normal interval growth in height and weight|normal BMI||high BMI|low BMI||toilet-trained|toilet training in process|goes to bathroom and urinates by self||age-appropriate development|some milestones not achieved|"][textarea cols=50 rows=2]
NUTRITION: discussed and/or handout provided, [checkbox name="nutrition" value="food variety|adequate daily intake of fruits and vegetables|adequate daily intake of calcium/iron|limiting juice/soda||good appetite|eats independently||no concerns identified|"][textarea cols=50 rows=2]                                     
DENTAL: discussed and/or handout provided, [checkbox name="dental" value="brushing twice daily||reports dental home|no dental home||no concerns identified|"][textarea cols=50 rows=2]
FAMILY: discussed and/or handout provided, [checkbox name="family" value="one-parent|two-parent|siblings|good sibling relationships||adequate living situation|attends daycare|stays at home||housing problems|custody issues|social services||no interval changes||no concerns identified|"][textarea cols=50 rows=2]
BEHAVIOR & SOCIAL: discussed and/or handout provided, [checkbox name="social" value="playing and sharing with others|playing make-believe|limiting screen time|reading and playing together||no concerns identified|"][textarea cols=50 rows=2]
LANGUAGE: discussed and/or handout provided, [checkbox name="language" value="using 3-word sentences|speech mostly intelligible to strangers|understanding simple prepositions (on, under)|telling a story from book or TV|using 'bigger' or 'shorter'||no concerns identified|"][textarea cols=50 rows=2]
GROSS MOTOR: discussed and/or handout provided, [checkbox name="gross" value="getting dressed by self||no concerns identified|"][textarea cols=50 rows=2]
FINE MOTOR: discussed and/or handout provided, [checkbox name="fine" value="drawing circle|drawing person with head and one other body part|cuting with scissors||no concerns identified|"][textarea cols=50 rows=2]
SAFETY: discussed and/or handout provided, [checkbox name="safety" value="choking prevention|home safety: window falls, burns, pets, guns||car safety|water safety||smoking household|firearms in home||no concerns identified|"][textarea cols=50 rows=2]



.
ROS
10-point review of systems was performed and results were negative except for any positive results below
General:[textarea name="variable_5" default=" does not report fever, tired, changed behavior, fussy, or weight changes"]
HEENT:[textarea name="variable_6" default=" does not report headache, scalp swelling, facial swelling, eye redness/discharge, itching, periorbital swelling, earache, ear discharge, wax, nasal congestion, rhinorrhea, bleeding, mouth sores, infection, sore throat, hoarseness, or swollen neck glands"]
Chest/Respiratory:[textarea name="variable_8" default=" does not report shortness of breath, cough, phlegm, or wheezing"]
GI:[textarea name="variable_9" default=" does not report poor appetite, nausea, vomiting, abdominal pain, constipation, diarrhea, or rectal itching/bleeding"]
GU:[textarea name="variable_10" default=" does not report dysuria, hematuria, frequency, urine odor, discharge, or skin lesion/rash"]
MSK:[textarea name="variable_11" default=" does not report limping, hip pain, knee pain, arthralgias, localized pain/swelling"]
Neurologic:[textarea name="variable_13" default=" does not report seizures,  balance problems, weakness, or frequent falls"]
Psychiatric:[textarea name="variable_14" default=" does not report anxiety, mood swings, behavioral issues, or sleep problems"]
Dermatologic:[textarea name="variable_12" default=" does not report rashes, redness, pruritus, swelling, bruising, or wounds"]
Hematologic/lymphatic:[textarea name="variable_16" default=" does not report abnormal bleeding/bruising"]



.
VACCINATION: [checkbox name="preventative" value="UTD|missing shots||administered today|deferred|declined|"][textarea cols=50 rows=2]
OFFICE DIAGNOSTICS: [checkbox name="office_diag" value="H&H|UA||normal|non-specific changes|abnormal||discussed with parent||none performed today|"][textarea cols=50 rows=2]
Appearance: [checkbox name="appearance" value="well-appearing|active|interactive||crying|consolable||NWOB|moist mucous membranes|age-appropriate behavior||inconsolable|irritable|uncooperative with exam|"][textarea cols=50 rows=2]
Head/Face: [checkbox name="head" value="normocephalic, atraumatic|symmetrical face|"][textarea cols=50 rows=2]
Eyes: [checkbox name="eyes" value="normal vision for age|unable to complete vision screen||vision 20/40 or better in both eyes|failed vision screen||red reflex present bilaterally|fixes and follows|extraocular eye movements intact|pupils equal round reactive to light|clear conjunctiva w/o exudates or hemorrhage||glasses||conjunctival injection|epiphora|conjunctival exudate|allergic shiners|dysconjugate gaze|"][textarea cols=50 rows=2]
Ears: [checkbox name="ears" value="symmetrical & intact auricles bilaterally|clear canals without erythema or discharge|TMs normal in appearance|"][textarea cols=50 rows=2]
Nose: [checkbox name="nose" value="nares patent bilaterally|septum midline|mucosa pink & moist||swollen & boggy mucosa|mucosal congestion|clear discharge|yellow discharge|crusty discharge|"][textarea cols=50 rows=2]
Mouth: [checkbox name="mouth" value="no oral lesions or gingivitis|normal dentition for age|"][textarea cols=50 rows=2]
Throat: [checkbox name="throat" value="normal voice|patent pharynx w/o swelling or exudates||hoarseness|vesicles on soft palate|petechiae on soft palate|pharyngeal erythema w/o exudates|"][textarea cols=50 rows=2]
Neck: [checkbox name="neck" value="symmetric with free painless ROM and no masses|supple|no LAD||anterior LAD|posterior LAD|"][textarea cols=50 rows=2]
Chest/Lungs: [checkbox name="lungs" value="unlabored respirations, symmetrical chest expansion|clear and equal breath sounds bilaterally||decreased bilaterally|wheezing|"][textarea cols=50 rows=2]
CV: [checkbox name="cv" value="regular rhythm|no murmurs||tachycardia|irregular heart rhythm|systolic murmur|"][textarea cols=50 rows=2]
Abdomen: [checkbox name="abd" value="no distension|normal active bowel sounds|soft non-tender|no obvious palpable masses||umbilical hernia|diffuse tenderness over entire abdomen w/o RRG|"][textarea cols=50 rows=2]
GU: [checkbox name="gu" value="declined exam||normal external genitalia|testes down bilaterally||uncircumcised|circumcised|"][textarea cols=50 rows=2]
MSK: [checkbox name="spine" value="no gross deformities|ambulates w/o limp or alteration in gait|normal spine|strength, tone, & bulk symmetrical|"][textarea cols=50 rows=2]
Neuro: [checkbox name="neuro" value="ambulates w/o limp or alteration in gait|social|appropriate for age speech|"][textarea cols=50 rows=2]
Skin: [checkbox name="skin" value="grossly intact, no rashes|warm and well perfused|no bruising|"][textarea cols=50 rows=2]


A/P:
[checkbox name="ap" value="well child|"][textarea cols=50 rows=2]


.
ORDERS - RX: [checkbox name="order_RX" value="OTC||electronic|paper|given to MA to be transmitted to pharmacy||none|"][textarea cols=50 rows=1]
ORDERS - LABS: [checkbox name="order_lab" value="CBC|CMP|TSH|Lipids|A1C|lead|UA||none|"][textarea cols=50 rows=2]
ORDERS - FORMS/RELEASE/CLEARANCE: [checkbox name="clearance" value="daycare physical||none"][textarea cols=50 rows=1]
INSTRUCTED ON: milestones, wellness, screening findings, exam findings, [checkbox name="instruct" value="POC, reporting medication side effects immediately, indications for immediate direct evaluation and/or contacting emergency services|"][textarea cols=50 rows=1]
PLAN OF CARE: [checkbox name="discussed" value="verbalized understanding of & agreement with POC|did not agree with my POC – will seek second opinion/further care elsewhere|"][textarea cols=50 rows=2]
FOLLOW UP: one year, sooner if concerns arise, [checkbox name="next" value="RTC 24 hours|RTC 2-3 days|RTC 1-2 weeks|RTC 3-4 weeks|"][textarea cols=50 rows=2]
PARENTAL BEHAVIOR: [checkbox name="behavior" value="calm|respectful||anxious|suspicious|irritable|frustrated||forceful|insisting on particular medication, test, referral, or accommodation||argumentative|hostile|raising voice|agitated||previous providers/staff criticisms|verbal threats||withdrawn|hypoverbal|"][textarea cols=50 rows=2]
BARRIERS TO CARE: [checkbox name="barriers" value="social/financial problems||incomplete history  d/t parental lack of knowledge/affect|incomplete history d/t language barrier||vague shifting complaints|history not supported by objective findings|supporting documentation unavailable||poor cooperation with exam|poor compliance with POC|intolerance of/therapeutic failure on multiple meds||lack of motivation|negative attitude to diagnostic impression & proposed tx||none identified|"][textarea cols=50 rows=1]