Pediatrics
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approximately 180 views since hunter-gatherers domesticated animals.
[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]

CONCERNS/QUESTIONS:
[checkbox name="cc" value="no concerns reported||cold|fever|runny nose|nasal congestion|earache/pulling on ear(s)|sore throat|cough|stridor|wheezing|rash||poor appetite|abd pain|diarrhea|nausea|dysuria|| consider formal screening and/or evaluation|"][textarea cols=50 rows=3]

SCREENING/QUESTIONNAIRE:
[checkbox name="screens" value="none||age-specific questionnaire provided & reviewed|"][textarea cols=50 rows=3]

SPECIAL NEEDS:
[checkbox name="special" value="none| "][textarea cols=50 rows=2]

INTERVAL HISTORY:
[checkbox name="interval" value="day care/school attendance|sick contact|consumption of food outside home|travel|ER/UC visit|hospitalization/surgery/procedure|diagnostic/laboratory studies|specialty consults|new/changed medications|ABX use|"][textarea cols=50 rows=3]

MEDICATIONS:
[checkbox name="medications" value="none reported||Rx|OTC||reports no side effects|reports side effects||effective|partially effective|not effective||taking as prescribed|not taking as prescribed|did not try|"][textarea cols=50 rows=2]

PMH:
[checkbox name="pmh" value="reviewed|non-contributory||immunization UTD|missing shots||frequent infections|frequent ABX use|asthma|allergies|eczema|"][textarea cols=50 rows=3]

SOCIAL HISTORY:
[checkbox name="social" value="no changes||child care|siblings||working parent|single parent||housing problems|custody issues|social services|"][textarea cols=50 rows=2]

GROWTH/DEVELOPMENT/ANTICIPATORY GUIDANCE:
discussed and/or handout provided
[checkbox name="development" value="no concerns raised||normal interval growth in height and weight|normal weight-for-length||puts on clothes with help|jumps up and down|walks up steps using one foot then the other|runs well without falling||pokes food with fork|washes and dries hands|grasps crayon with thumb
and fingers|catches large ball||urinates in a potty or toilet|toilet training not achieved|toilet training in progress|toilet training achieved||plays pretend with toys or dolls, plays with other people||can be understood|can put 3 to 4 words together|uses pronouns correctly|points to body parts|knows animal sounds|knows at least one color||age-appropriate development|some milestones not achieved|"][textarea cols=50 rows=2]

BEHAVIOR:
discussed and/or handout provided
[checkbox name="behavior" value="no concerns raised||emerging independence|"][textarea cols=50 rows=2]

FAMILY ROUTINES:
discussed and/or handout provided
[checkbox name="family" value="family meals, family activities, reading together|setting limits, consistency in the child’s environment|giving choices|screen time less than 2 hours/d|"][textarea cols=50 rows=2]

NUTRITION:
discussed and/or handout provided
[checkbox name="nutrition" value="no concerns raised|good appetite|good food variety|daily fruits and vegetables|adequate iron-containing foods|adequate calcium-containing foods|milk less 16 oz|"][textarea cols=50 rows=2]

DENTAL:
discussed and/or handout provided
[checkbox name="dental" value="no concerns raised||brushes teeth with help||fluoride in water source|fluoride via oral supplement||reports dental home|no dental home|"][textarea cols=50 rows=2]

SLEEP:
discussed and/or handout provided
[checkbox name="sleep" value="no concerns raised|"][textarea cols=50 rows=2]

SAFETY:
discussed and/or handout provided
[checkbox name="safety" value="no concerns raised||appropriate supervision, fire and burns, outdoor safety, car safety, sun exposure, water safety, dogs|smoking household|firearms in home|"][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]

Skin:
[checkbox name="skin" value="pink, normal turgor|no rashes|no bruising|"][textarea cols=50 rows=2]

HEAD:
[checkbox name="head" value="normocephalic and atraumatic||scalp tenderness|plagiocephaly|swelling|"][textarea cols=50 rows=2]

EYES:
[checkbox name="eyes" value="fixes and follows|extraocular eye movements intact. Red reflex present bilaterally|no opacification|"][textarea cols=50 rows=2]

ENT:
[checkbox name="ent" value="normal canals & TMs, normal external nose|no dental decay, no oral lesions|op w/o swelling or exudates|"][textarea cols=50 rows=2]

Neck:
[checkbox name="neck" value="supple, no significant LAD|"][textarea cols=50 rows=2]

Chest/Lungs:
[checkbox name="chest" value="unlabored respirations, symmetric chest expansion, clear and equal breath sounds bilaterally|"][textarea cols=50 rows=2]

Heart:
[checkbox name="heart" value="regular rate & rhythm, no murmurs|"][textarea cols=50 rows=2]

Abdomen:
[checkbox name="abdomen" value="soft, nondistended, nontender, no obvious palpable masses|"][textarea cols=50 rows=2]

Genitalia:
[checkbox name="genitalia" value="not examined per parental request||normal female external genitalia||normal male external genitalia|uncircumcised|circumcised|testes down bilaterally|"][textarea cols=50 rows=2]

Musculoskeletal:
[checkbox name="extremities" value="no gross deformities, normal spine|"][textarea cols=50 rows=2]

Neuro:
[checkbox name="neuro" value="normal gait & coordination|social|able to answer simple questions and follow simple commands|"][textarea cols=50 rows=2]

OFFICE DIAGNOSTICS:
[checkbox name="office_diag" value="none performed today||normal|non-specific changes|no acute findings||discussed with patient/SO|official report to follow|"][textarea cols=50 rows=2]

A/P:
[textarea cols=50 rows=5]

VACCINATION:
[checkbox name="preventative" value="UTD|today|deferred|declined|"][textarea cols=50 rows=2]

LABS:
[checkbox name="order_lab" value="none||CBC|"][textarea cols=50 rows=2]

RX:
[checkbox name="order_RX" value="none||OTC||electronic|paper|given to MA to be transmitted to pharmacy|"][textarea cols=50 rows=1]

OUTSIDE REFERRALS:
[checkbox name="order_refer" value="none|"] [textarea cols=50 rows=2]

FORMS/RELEASE/CLEARANCE:
[checkbox name="clearance" value="none||daycare physical|"][textarea cols=70 rows=1]

INSTRUCTED ON:
exam/screening findings, POC, reporting medication side effects immediately, appropriate follow up, 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=3]

SAFETY:
[checkbox name="discharge" value="no safety concerns at this time||safety concerns d/t parental knowledge/mood|safety concerns d/t social issues|"][textarea cols=50 rows=2]

FOLLOW UP:
3 years of age, sooner if concerns arise|
[checkbox name="next" value="RTC 24 hours|RTC 2-3 days|RTC 1 week|RTC 4 weeks|"][textarea cols=50 rows=2]

PARENTAL BEHAVIOR:
[checkbox name="behavior" value="calm|pleasant|respectful||anxious|fearful|suspicious|irritable|frustrated|crying||forceful|insisting on particular medication, test, referral, or accommodation|argumentative||hostile|raising voice|agitated|cursing, swearing||previous providers/staff criticisms|verbal threats|sexual remarks|racist remarks||flat affect|bradykinetic|indifferent|appears to be responding to internal psychotic process|"][textarea cols=50 rows=2]

BARRIERS TO CARE:
[checkbox name="barriers" value="none noted at this time||incomplete history d/t parental anxiety/behavior|incomplete history d/t parental lack of knowledge|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 on parent's part|negative parental attitude to diagnostic impression & proposed tx|"][textarea cols=50 rows=1]


CONCERNS/QUESTIONS:


SCREENING/QUESTIONNAIRE:


SPECIAL NEEDS:


INTERVAL HISTORY:


MEDICATIONS:


PMH:


SOCIAL HISTORY:


GROWTH/DEVELOPMENT/ANTICIPATORY GUIDANCE:
discussed and/or handout provided


BEHAVIOR:
discussed and/or handout provided


FAMILY ROUTINES:
discussed and/or handout provided


NUTRITION:
discussed and/or handout provided


DENTAL:
discussed and/or handout provided


SLEEP:
discussed and/or handout provided


SAFETY:
discussed and/or handout provided


Appearance:


Skin:


HEAD:


EYES:


ENT:


Neck:


Chest/Lungs:


Heart:


Abdomen:


Genitalia:


Musculoskeletal:


Neuro:


OFFICE DIAGNOSTICS:


A/P:


VACCINATION:


LABS:


RX:


OUTSIDE REFERRALS:


FORMS/RELEASE/CLEARANCE:


INSTRUCTED ON:
exam/screening findings, POC, reporting medication side effects immediately, appropriate follow up, indications for immediate direct evaluation and/or contacting emergency services


PLAN OF CARE:


SAFETY:


FOLLOW UP:
3 years of age, sooner if concerns arise|


PARENTAL BEHAVIOR:


BARRIERS TO CARE:

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