Assessment & Plan Elements
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PHYSICAL EXAM:
[checkbox name="PEsports" value="Sports Eval"][conditional field="PEsports" condition="(PEsports).is('Sports Eval')"]
-Vitals: [checkbox value="reviewed|no remarkable abnormalities|hypertensive"]
-Visual acuity: [checkbox value="reviewed|no remarkable abnormalities|decreased visual acuity"]
-Hearing: [text default="no overt/gross hearing loss detected" size="80"]
-General: [text default="WD/WN/NAD, non-ill appearing" size="80"]
-Heart: [text memo="free text" memo_size="small" size="80"][checkbox value="RRR|normal S1/S2|No M/R/G|No S3/S4 auscultated|no murmur detected on dynamic/valsalva testing|no friction rub"] [comment memo="abnormals" memo_color="orange" memo_size="small"][checkbox name="examheartabn1" value="MURMUR AUSCULTATED"][/conditional][conditional field="examheartabn1" condition="(examheartabn1).is('MURMUR AUSCULTATED')"] - GRADE [text size="3"]/6 [select value="SYSTOLIC EJECTION|SYSTOLIC|DIASTOLIC|HOLOSYSTOLIC"] HEARD BEST AT [select value="R|L"] [checkbox value="UPPER STERNAL BORDER|LOWER STERNAL BORDER|APEX|WITH DYNAMIC/VALSALVA TEST"]
[/conditional][conditional field="PEsports" condition="(PEsports).is('Sports Eval')"]
-Lungs: [text memo="free text" memo_size="small" size="80"][checkbox value="CTAB|BSE b/l|no wheezes|no crackles|no rhonchi"] [comment memo="abnormals" memo_color="orange" memo_size="small"][checkbox name="examlungsabn1" value="WHEEZING-"][/conditional][conditional field="examlungsabn1" condition="(examlungsabn1).is('WHEEZING-')"] [checkbox value="EXPIRATORY|INSPIRATORY|B/L LUNGS|R LUNG|L LUNG|DIFFUSE|LOWER FIELD(S)|UPPER FIELD(S)"] [/conditional][conditional field="PEsports" condition="(PEsports).is('Sports Eval')"][checkbox name="examlungsabn2" value="RHONCHI-"][/conditional][conditional field="examlungsabn2" condition="(examlungsabn2).is('RHONCHI-')"] [checkbox value="EXPIRATORY|INSPIRATORY|B/L LUNGS|R LUNG|L LUNG|DIFFUSE|LOWER FIELD(S)|UPPER FIELD(S)"] [/conditional][conditional field="PEsports" condition="(PEsports).is('Sports Eval')"][checkbox name="examlungsabn3" value="BREATH SOUNDS DIMINISHED-"][/conditional][conditional field="examlungsabn3" condition="(examlungsabn3).is('BREATH SOUNDS DIMINISHED-')"] [checkbox value="B/L LUNGS|R LUNG|L LUNG|DIFFUSE|LOWER FIELD(S)|UPPER FIELD(S)"][/conditional][conditional field="PEsports" condition="(PEsports).is('Sports Eval')"]
-MSK: [comment memo="only select those MSK items that were abnormal" memo_size="small"]
[checklist value="Abnormalities/defects in Neck ROM|Abnormalities/defects in Resisted Shoulder Shrug|abnormalities/defects in resisted arm abduction at 90deg|Abnormalities/defects in active shoulder ext rotation at 90deg abduction & elbows at 90deg|Abnormalities/defects in Elbow ROM|Abnormalities/defects Wrist supination/pronation ROM|Abnormalities/defects in finger MCP/PIP/DIP ROM|Abnormalities/defects in hip/knee/ankle strength/ROM/stability (duck walk)|Abnormalities/defects in spine/shoulder height/alignment|Abnormalities/defects in calves/achilles tone/strength/ROM"][textarea memo="description of MSK abnormals" memo_size="small" memo_color="orange"]

[/conditional][checkbox name="PEwellvisit" value="Well Visit"][conditional field="PEwellvisit" condition="(PEwellvisit).is('Well Visit')"] for [select name="Q1" value="|1 week|2 week|1 month|2 month|4 month|6 month|9 month|12 month|15 month|18 month|2 year|3 year|4 year|5 year|6-10 year|11-14 year|15-18 year"] [select name="Q2" value="|female|male"] patient
[/conditional][conditional field="Q1|Q2" condition="((Q1).is('1 week')||(Q1).is('2 week')||(Q1).is('1 month'))&&((Q2).is('male'))"]
[text size=80 default="Skin: Normal turgor and without lesions."]
[text size=80 default="Eyes: Red reflex present bilaterally. Pupils equally round and reactive to light"]
[text size=80 default="Head: Normocephalic with age appropriate fontanelles."]
[text size=80 default="Peripheral Vessels: Normal pulses and perfusion."]
[text size=80 default="Heart: Regular rate and rhythm; normal S1 and S2; no murmurs, gallops, or rubs."]
[text size=80 default="Lungs: Unlabored respirations; symmetric chest expansion; clear breath sounds."]
[text size=80 default="Abdomen: Soft, without organomegaly. Bowel sounds normal. Nontender without rebound. No masses palpable. No distention."]
[text size=80 default="Genitalia: Normal male external genitalia. Testes descended bilaterally. No hernia present."]
[text size=80 default="Spine: Straight with no lesions."]
[text size=80 default="Joints: Hips with full range-of-motion; negative Barlow and Ortolani."]
[text size=80 default="Extremities: No clubbing, cyanosis, or edema. Normal upper and lower extremities."]
[text size=80 default="Mental Status: Alert and in no distress. Appropriate for age."]
[text size=80 default="Neuro: Normal reflexes; normal tone; no focal deficits appreciated. Appropriate for age."]

[/conditional][conditional field="Q1|Q2" condition="((Q1).is('1 week')||(Q1).is('2 week')||(Q1).is('1 month'))&&((Q2).is('female'))"]
[text size=80 default="Skin: Normal turgor and without lesions."]
[text size=80 default="Eyes: Red reflex present bilaterally. Pupils equally round and reactive to light"]
[text size=80 default="Head: Normocephalic with age appropriate fontanelles."]
[text size=80 default="Peripheral Vessels: Normal pulses and perfusion."]
[text size=80 default="Heart: Regular rate and rhythm; normal S1 and S2; no murmurs, gallops, or rubs."]
[text size=80 default="Lungs: Unlabored respirations; symmetric chest expansion; clear breath sounds."]
[text size=80 default="Abdomen: Soft, without organomegaly. Bowel sounds normal. Nontender without rebound. No masses palpable. No distention."]
[text size=80 default="Genitalia: Normal female external genitalia. No hernia present."]
[text size=80 default="Spine: Straight with no lesions."]
[text size=80 default="Joints: Hips with full range-of-motion; negative Barlow and Ortolani."]
[text size=80 default="Extremities: No clubbing, cyanosis, or edema. Normal upper and lower extremities."]
[text size=80 default="Mental Status: Alert and in no distress. Appropriate for age."]
[text size=80 default="Neuro: Normal reflexes; normal tone; no focal deficits appreciated. Appropriate for age."]

[/conditional][conditional field="Q1|Q2" condition="((Q1).is('2 month')||(Q1).is('4 month')||(Q1).is('6 month')||(Q1).is('9 month'))&&((Q2).is('male'))"]
[text size=80 default="General: Child appears age appropriate. "]
[text size=80 default="Vitals noted and stable."]
[text size=80 default="Skin: Normal turgor and without lesions."]
[text size=80 default="Head: Normocephalic with age appropriate fontanelles."]
[text size=80 default="Eyes: Conjunctivae noninjected; sclerae anicteric; lids without ptosis, edema, or erythema; extraocular movements intact; pupils equal, round, and reactive to light. Red reflex present bilaterally."]
[text size=80 default="ENT: TMs gray, sharp landmarks, mobile. Nose clear. Palate is complete. Dentition normal for age. Tonsils small and non-inflamed bilaterally."]
[text size=80 default="Lymph Nodes: No significant lymphadenopathy."]
[text size=80 default="Thyroid: No thyromegaly; trachea midline without masses."]
[text size=80 default="Breasts: Without lesions or drainage."]
[text size=80 default="Heart: Regular rate and rhythm; normal S1 and S2; no murmurs, gallops, or rubs."]
[text size=80 default="Lungs: Unlabored respirations; symmetric chest expansion; clear breath sounds; no wheezes, crackles, rales, rhonchi, or retractions."]
[text size=80 default="Abdomen: Soft, without organomegaly. Bowel sounds normal. Non-tender without rebound. No masses palpable. No distention."]
[text size=80 default="Genitalia: Normal male external genitalia; testes descended bilaterally; no hernia."]
[text size=80 default="Spine: Straight with no lesions."]
[text size=80 default="Joints: Full range of motion about all joints."]
[text size=80 default="Extremities: Peripheral pulses are equal. There is no clubbing, cyanosis or edema of the extremities. Capillary refill is less than 2 seconds."]
[text size=80 default="Gait: Normal and appropriate gait for age."]
[text size=80 default="Mental Status: Alert and in no distress. Appropriate for age."]
[text size=80 default="Neuro: Normal reflexes; normal tone; no focal deficits appreciated. Appropriate for age."]

[/conditional][conditional field="Q1|Q2" condition="((Q1).is('2 month')||(Q1).is('4 month')||(Q1).is('6 month')||(Q1).is('9 month'))&&((Q2).is('female'))"]
[text size=80 default="General: Child appears age appropriate. Vitals noted and stable."]
[text size=80 default="Skin: Normal turgor and without lesions."]
[text size=80 default="Head: Normocephalic with age appropriate fontanelles."]
[text size=80 default="Eyes: Conjunctivae noninjected; sclerae anicteric; lids without ptosis, edema, or erythema; extraocular movements intact; pupils equal, round, and reactive to light. Red reflex present bilaterally."]
[text size=80 default="ENT: TMs gray, sharp landmarks, mobile. Nose clear. Palate is complete. Dentition normal for age. Tonsils small and non-inflamed bilaterally."]
[text size=80 default="Lymph Nodes: No significant lymphadenopathy."]
[text size=80 default="Thyroid: No thyromegaly; trachea midline without masses."]
[text size=80 default="Breasts: Without lesions or drainage."]
[text size=80 default="Heart: Regular rate and rhythm; normal S1 and S2; no murmurs, gallops, or rubs."]
[text size=80 default="Lungs: Unlabored respirations; symmetric chest expansion; clear breath sounds; no wheezes, crackles, rales, rhonchi, or retractions."]
[text size=80 default="Abdomen: Soft, without organomegaly. Bowel sounds normal. Non-tender without rebound. No masses palpable. No distention."]
[text size=80 default="Genitalia: Normal female external genitalia."]
[text size=80 default="Spine: Straight with no lesions."]
[text size=80 default="Joints: Full range of motion about all joints."]
[text size=80 default="Extremities: Peripheral pulses are equal. There is no clubbing, cyanosis or edema of the extremities. Capillary refill is less than 2 seconds."]
[text size=80 default="Gait: Normal and appropriate gait for age."]
[text size=80 default="Mental Status: Alert and in no distress. Appropriate for age."]
[text size=80 default="Neuro: Normal reflexes; normal tone; no focal deficits appreciated. Appropriate for age."]

[/conditional][conditional field="Q1|Q2" condition="((Q1).is('12 month')||(Q1).is('15 month')||(Q1).is('18 month')||(Q1).is('2 year')||(Q1).is('3 year')||(Q1).is('4 year'))&&((Q2).is('male'))"]
[text size=80 default="General: Child appears age appropriate. Vitals noted and stable."]
[text size=80 default="Skin: Normal turgor and without lesions."]
[text size=80 default="Head: Normocephalic."]
[text size=80 default="Eyes: Conjunctivae noninjected; sclerae anicteric; lids without ptosis, edema, or erythema; extraocular movements intact; pupils equal, round, and reactive to light. Red reflex present bilaterally. Symmetric light reflex."]
[text size=80 default="ENT: TMs gray, sharp landmarks, mobile. Nose clear. Palate is complete. Dentition normal for age. Tonsils small and non-inflamed bilaterally."]
[text size=80 default="Lymph Nodes: No significant lymphadenopathy."]
[text size=80 default="Thyroid: No thyromegaly; trachea midline without masses."]
[text size=80 default="Breasts: Without lesions or drainage."]
[text size=80 default="Heart: Regular rate and rhythm; normal S1 and S2; no murmurs, gallops, or rubs. "]
[text size=80 default="Lungs: Unlabored respirations; symmetric chest expansion; clear breath sounds; no wheezes, crackles, rales, rhonchi, or retractions."]
[text size=80 default="Abdomen: Soft, without organomegaly. Bowel sounds normal. Non-tender without rebound. No masses palpable. No distention."]
[text size=80 default="Genitalia: Normal male external genitalia; testes descended bilaterally; no hernia."]
[text size=80 default="Spine: Straight with no lesions."]
[text size=80 default="Joints: Full range of motion about all joints."]
[text size=80 default="Extremities: Peripheral pulses are equal. There is no clubbing, cyanosis or edema of the extremities. Capillary refill is less than 2 seconds."]
[text size=80 default="Gait: Normal and appropriate gait for age."]
[text size=80 default="Mental Status: Alert and in no distress. Appropriate for age."]
[text size=80 default="Neuro: Normal reflexes; normal tone; no focal deficits appreciated. Appropriate for age."]

[/conditional][conditional field="Q1|Q2" condition="((Q1).is('12 month')||(Q1).is('15 month')||(Q1).is('18 month')||(Q1).is('2 year')||(Q1).is('3 year')||(Q1).is('4 year'))&&((Q2).is('female'))"]
[text size=80 default="General: Child appears age appropriate. Vitals noted and stable."]
[text size=80 default="Skin: Normal turgor and without lesions."]
[text size=80 default="Head: Normocephalic."]
[text size=80 default="Eyes: Conjunctivae noninjected; sclerae anicteric; lids without ptosis, edema, or erythema; extraocular movements intact; pupils equal, round, and reactive to light. Red reflex present bilaterally. Symmetric light reflex."]
[text size=80 default="ENT: TMs gray, sharp landmarks, mobile. Nose clear. Palate is complete. Dentition normal for age. Tonsils small and non-inflamed bilaterally."]
[text size=80 default="Lymph Nodes: No significant lymphadenopathy."]
[text size=80 default="Thyroid: No thyromegaly; trachea midline without masses."]
[text size=80 default="Breasts: Without lesions or drainage."]
[text size=80 default="Heart: Regular rate and rhythm; normal S1 and S2; no murmurs, gallops, or rubs. "]
[text size=80 default="Lungs: Unlabored respirations; symmetric chest expansion; clear breath sounds; no wheezes, crackles, rales, rhonchi, or retractions."]
[text size=80 default="Abdomen: Soft, without organomegaly. Bowel sounds normal. Non-tender without rebound. No masses palpable. No distention."]
[text size=80 default="Genitalia: Normal female external genitalia."]
[text size=80 default="Spine: Straight with no lesions."]
[text size=80 default="Joints: Full range of motion about all joints."]
[text size=80 default="Extremities: Peripheral pulses are equal. There is no clubbing, cyanosis or edema of the extremities. Capillary refill is less than 2 seconds."]
[text size=80 default="Gait: Normal and appropriate gait for age."]
[text size=80 default="Mental Status: Alert and in no distress. Appropriate for age."]
[text size=80 default="Neuro: Normal reflexes; normal tone; no focal deficits appreciated. Appropriate for age."]

[/conditional][conditional field="Q1|Q2" condition="((Q1).is('5 year')||(Q1).is('6-10 year')||(Q1).is('11-14 year')||(Q1).is('15-18 year'))&&((Q2).is('male'))"]
[text size=80 default="General: Child appears age appropriate. Vitals noted and stable."]
[text size=80 default="Skin: Normal turgor and without lesions."]
[text size=80 default="Head: Normocephalic."]
[text size=80 default="Eyes: Conjunctivae noninjected; sclerae anicteric; lids without ptosis, edema, or erythema; extraocular movements intact; pupils equal, round, and reactive to light. Symmetric light reflex, normal fundi."]
[text size=80 default="ENT: TMs gray, sharp landmarks, mobile. Nose clear. Palate is complete. Dentition normal for age. Tonsils small and non-inflamed bilaterally."]
[text size=80 default="Lymph Nodes: No significant lymphadenopathy."]
[text size=80 default="Thyroid: No thyromegaly; trachea midline without masses."]
[text size=80 default="Breasts: Without lesions or drainage."]
[text size=80 default="Heart: Regular rate and rhythm; normal S1 and S2; no murmurs, gallops, or rubs. "]
[text size=80 default="Lungs: Unlabored respirations; symmetric chest expansion; clear breath sounds; no wheezes, crackles, rales, rhonchi, or retractions."]
[text size=80 default="Abdomen: Soft, without organomegaly. Bowel sounds normal. Non-tender without rebound. No masses palpable. No distention."]
[text size=80 default="Genitalia: Normal male external genitalia; testes descended bilaterally; no hernia."]
[text size=80 default="Spine: Straight with no lesions."]
[text size=80 default="Joints: Full range of motion about all joints."]
[text size=80 default="Extremities: Peripheral pulses are equal. There is no clubbing, cyanosis or edema of the extremities. Capillary refill is less than 2 seconds."]
[text size=80 default="Gait: Normal and appropriate gait for age."]
[text size=80 default="Mental Status: Alert, oriented, in no distress. Appropriate for age."]
[text size=80 default="Neuro: Normal reflexes; normal tone; no focal deficits appreciated. Appropriate for age."]

[/conditional][conditional field="Q1|Q2" condition="((Q1).is('5 year')||(Q1).is('6-10 year')||(Q1).is('11-14 year')||(Q1).is('15-18 year'))&&((Q2).is('female'))"]
[text size=80 default="General: Child appears age appropriate. Vitals noted and stable."]
[text size=80 default="Skin: Normal turgor and without lesions."]
[text size=80 default="Head: Normocephalic."]
[text size=80 default="Eyes: Conjunctivae noninjected; sclerae anicteric; lids without ptosis, edema, or erythema; extraocular movements intact; pupils equal, round, and reactive to light. Symmetric light reflex, normal fundi."]
[text size=80 default="ENT: TMs gray, sharp landmarks, mobile. Nose clear. Palate is complete. Dentition normal for age. Tonsils small and non-inflamed bilaterally."]
[text size=80 default="Lymph Nodes: No significant lymphadenopathy."]
[text size=80 default="Thyroid: No thyromegaly; trachea midline without masses."]
[text size=80 default="Breasts: Without lesions or drainage."]
[text size=80 default="Heart: Regular rate and rhythm; normal S1 and S2; no murmurs, gallops, or rubs. "]
[text size=80 default="Lungs: Unlabored respirations; symmetric chest expansion; clear breath sounds; no wheezes, crackles, rales, rhonchi, or retractions."]
[text size=80 default="Abdomen: Soft, without organomegaly. Bowel sounds normal. Non-tender without rebound. No masses palpable. No distention."]
[text size=80 default="Genitalia: Normal female external genitalia."]
[text size=80 default="Spine: Straight with no lesions."]
[text size=80 default="Joints: Full range of motion about all joints."]
[text size=80 default="Extremities: Peripheral pulses are equal. There is no clubbing, cyanosis or edema of the extremities. Capillary refill less than 2 seconds."]
[text size=80 default="Gait: Normal and appropriate gait for age."]
[text size=80 default="Mental Status: Alert, oriented, in no distress. Appropriate for age."]
[text size=80 default="Neuro: Normal reflexes; normal tone; no focal deficits appreciated. Appropriate for age."]

[/conditional][comment memo="coding blurbs" memo_size="small"][checkbox value="-The above SocHx/Allergies/Meds/PMHx/PSHx/FMHx were reviewed & updated at today's visit.
"][checkbox value="-The scribe/medic/nurse/student assisted in collecting and documenting the patient's history.
-I have personally reviewed it and verified its accuracy.
"][checkbox value="-The scribe/medic/nurse/student assisted in documenting the physical exam performed by me.
-I have personally reviewed it and verified its accuracy.
"][checkbox value="-Laboratory results as displayed were reviewed and interpreted
"][checkbox value="-Radiologic study results as displayed were reviewed and interpreted
"][checkbox value="-Radiologic study images which results are displayed in note were reviewed and interpreted
"]
ASSESSMENT/PLAN:
[conditional field="PEsports" condition="(PEsports).is('Sports Eval')"]#PRE-PARTICIPATION SPORTS EVALUATION Z02.5
-Neuro considerations- [checkbox value="no concerns|epilepsy in hx/fmhx|hx of concussion|conditions stable|warrants further eval"]
-BH considerations- [checkbox value="no concerns|euthymic|low-risk|warrants further eval"]
-BMI & Eating d/o screening- [checkbox value="no concerns|underweight|concern for possible eating disorder|overweight|obese|discussed nutrition & exercise|warrants further eval"]
-Cardiovasc considerations- [checkbox value="no concerns|EKG performed and normal|physiologic murmur|concerning murmur|warrants further eval"]
-Pulmonary considerations- [checkbox value="no concerns|asthma hx|well-controlled|uncontrolled|has rescue inhaler|rescue inhaler rx'd|discussed appropriate use of inhaler|needs PFT|warrants further eval"]
-Ortho/MSK considerations- [checkbox value="no concerns|evidence of previous injuries|previous injuries appear well healed and stable|concern for scoliosis|concern for instability of joint(s)|warrants further eval"]
-Hematologic concerns- [checkbox value="no concerns|sickle cell fmhx|sickle cell trait present|sickle cell disease|possible bleeding d/o in fmhx|warrants further eval"]

-Overall Assessment: [select value="Low risk. Cleared for participation in selected sport|Not cleared for participation selected sport|Needs further workup prior to clearance for selected sport"]

-Recommendations for further eval/workup: [checkbox value="no further eval needed|metabolic labs for obesity|Neuro referral|BH referral|EKG referral|EchoCG ordered|Cards referral|Pulm referral|PFT ordered|Ortho/SM referral|labs checking for sickle cell|labs checking for bleeding disorders"]
-Education: [checkbox value="discussed risk of harm from identified health conditions with participation in certain sports|discussed avoidance of texting while driving|discussed avoidance of drug and alcohol use|discussed prevention of obesity|discussed eating disorders|discussed depression and suicidality|discussed bullying (especially online)|discussed sexual activity and contraception/STI prevention"]

-Disposition: [checkbox value="no routine f/u needed|f/u with PCM regarding chronic health issues identified|f/u for re-evaluation for sports participation after completing above workup"]
[checkbox name="sportscontralist" memo="List of contraindications for sports participation" memo_size="small" value=""]
[/conditional][conditional field="sportscontralist" condition="(sportscontralist).is('')"][comment memo="-Active myocarditis or pericarditis
-Hypertrophic cardiomyopathy
-Severe hypertension until controlled by therapy (static resistance activities, such as weight lifting, are particularly contraindicated)
-Suspected coronary artery disease until fully evaluated (patients with impaired resting left ventricular systolic function less than 50%, or exercise-induced ventricular dysrhythmias, or exercise-induced ischemia on exercise stress testing are at greatest risk of sudden death)
-Long QT interval syndrome
-History of recent concussion and symptoms of postconcussion syndrome (no contact or collision sports)
-Poorly controlled convulsive disorder (no archery, riflery, swimming, weight lifting or power lifting, strength training or sports involving heights)
-Recurrent episodes of burning upper-extremity pain or weakness, or episodes of transient quadriplegia until stability of cervical spine can be assured (no contact or collision sports)
-Sickle cell disease (no high-exertion, contact or collision sports)
-Eating disorder where athlete is not compliant with therapy and follow-up, or where there is evidence of diminished performance or potential injury because of eating disorder
-Acute enlargement of spleen or liver" memo_size="small"][/conditional][conditional field="PEwellvisit" condition="(PEwellvisit).is('Well Visit')"]#Wellness Visit [comment memo="
Z00.129 peds well with no new abnormals found
Z00.121 peds well with NEW abnormals
Z02.0 peds school/preschool physical" memo_size="small"]
[checkbox value="-Normal growth and development.
"][checkbox value="-Approved for all routine preventive medicine services, including immunizations
"][checkbox value="-Abuse/neglect, functional status, nutrition and pain assessed and no further evaluation is needed.
"][comment memo="Vaccination status/discussion" memo_size="small"][checkbox value="-Recommended immunization schedule reviewed and discussed, including side effects, risks, and benefits of immunizations.
"][checkbox value=" -Patient uptodate.
"][checkbox value=" -Patient NOT uptodate.
"][checkbox value=" -Immunizations per recommended schedule to be given today.
"][checkbox value=" -No immunizations to be given today.
"][checkbox value=" -Parent/patient agreed to recommended catchup immunizations today.
"][checkbox value=" -Parent/patient declined recommended immunizations today (will continue to address hesistancy at next visit)
"][/conditional][conditional field="Q1" condition="(Q1).is('1 week')||(Q1).is('2 week')||(Q1).is('1 month')"]-Injury prevention, health promotion issues discussed including age specific guidance:
[comment memo="anticipatory guidance" memo_size="small"][checkbox value=" -Infant should sleep on back
"][checkbox value=" -Pets (keep separated from child)
"][checkbox value=" -Use of car restraints
"][checkbox value=" -Do not leave near water or where child can fall
"][checkbox value=" -Assure water heater temp. set less than 120 degrees and test fire alarms.
"][comment memo="other specifics" memo_size="small"][checkbox value="-Hepatitis B vaccination to be given today.
"][checkbox value="-Advised return to clinic at 2 months of age, or sooner if concerns arise.
"][/conditional][conditional field="Q1" condition="(Q1).is('2 month')"]-Injury prevention, health promotion issues discussed including age specific guidance:
[comment memo="anticipatory guidance" memo_size="small"][checkbox value=" -Infant should sleep on back.
"][checkbox value=" -Use car restraints.
"][checkbox value=" -Do not leave the child near water or where the child can fall.
"][checkbox value=" -Do not use walkers or small toys.
"][checkbox value=" -Burn prevention reviewed.
"][comment memo="other specifics" memo_size="small"][checkbox value="-Immunizations to be given today per schedule: HBV-Hib, DTaP, and IPV (Hepatitis B-Haemophilus influenza, Diphtheria-Tetanus-acellular Pertussis and polio), PCV (Pneumococcal), Rota.
"][checkbox value="-Advised return to clinic at 4 months of age, or sooner if concerns arise.
"][/conditional][conditional field="Q1" condition="(Q1).is('4 month')"]-Injury prevention, health promotion issues discussed including age specific guidance:
[comment memo="anticipatory guidance" memo_size="small"][checkbox value=" -Use car restraints
"][checkbox value=" -Do not leave near water or where the child can fall.
"][checkbox value=" -Do not use walkers or small toys.
"][checkbox value=" -Avoidance of plastic's suffocation.
"][checkbox value=" -Burn prevention.
"][comment memo="other specifics" memo_size="small"][checkbox value="-Immunizations to be given today per schedule: Hib, DTaP, and IPV (Hepatitis B- Haemophilus influenza, Diphtheria-Tetanus, acellular Pertussis and polio), PCV7 (Pneumococcal), Rotavirus.
"][checkbox value="-Advised return to clinic at 6 months of age, or sooner if concerns arise.
"][/conditional][conditional field="Q1" condition="(Q1).is('6 month')"]-Injury prevention, health promotion issues discussed including age specific guidance:
[comment memo="anticipatory guidance" memo_size="small"][checkbox value=" -Avoid rush to introduce solid foods. Main nutritional source is breastmilk/formula.
"][checkbox value=" -Use of car restraints.
"][checkbox value=" -Supervise around water or where the child can fall.
"][checkbox value=" -Use gates to block stairway.
"][checkbox value=" -Be careful of cords and plants.
"][checkbox value=" -Do not use walkers or allow with small objects.
"][checkbox value=" -Burn prevention.
"][comment memo="other specifics" memo_size="small"][checkbox value="-Immunizations to be given today per schedule: DTaP (Diphtheria-Tetanus-acellular Pertussis)/HBV (hepatitis)/PCV (Pneumococcal)/ROTA (Rotavirus).
"][checkbox value="-Advised return to clinic at 9 months of age, or sooner if concerns arise.
"][/conditional][conditional field="Q1" condition="(Q1).is('9 month')"]-Injury prevention, health promotion issues discussed including age specific guidance:
[comment memo="anticipatory guidance" memo_size="small"][checkbox value=" -Avoid rush to introduce solid foods. Main nutritional source is breastmilk/formula.
"][checkbox value=" -Appropriate family interactions.
"][checkbox value=" -Appropriate feeding routine.
"][checkbox value=" -Appropriate infant independence.
"][comment memo="other specifics" memo_size="small"][checkbox value="-Advised return to clinic at 12 months of age, or sooner if concerns arise.
"][/conditional][conditional field="Q1" condition="(Q1).is('12 month')"]-Injury prevention, health promotion issues discussed including age specific guidance:
[comment memo="anticipatory guidance" memo_size="small"][checkbox value=" -Nutrition - appropriate transitioning from breastmilk/formula to solids.
"][checkbox value=" -Choking hazards.
"][checkbox value=" -Use of gates.
"][checkbox value=" -Caution around open water.
"][checkbox value=" -Falling.
"][checkbox value=" -Sunscreen if summer.
"][checkbox value=" -Smoke detectors, smoke free environment.
"][checkbox value=" -Lower crib mattress.
"][checkbox value=" -Check window guards.
"][checkbox value=" -Supervise near dogs, lawnmowers, streets, and driveways.
"][checkbox value=" -Burn prevention.
"][checkbox value=" -Recommended to eat meals as family.
"][checkbox value=" -2 snacks low in sugar daily.
"][checkbox value=" -Don't put toddler to bed with bottle.
"][checkbox value=" -Brush teeth daily, use of fluoride.
"][checkbox value=" -Poison prevention:
-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.
"][comment memo="other specifics" memo_size="small"][checkbox value="-Immunizations to be given today per schedule: Hib/MMR/PCV/Varicella/HAV.
"][checkbox value="-Advised return to clinic at 15 months of age, or sooner if concerns arise.
"][/conditional][conditional field="Q1" condition="(Q1).is('15 month')||(Q1).is('18 month')"]-Injury prevention, health promotion issues discussed including age specific guidance:
[comment memo="anticipatory guidance" memo_size="small"][checkbox value=" -Choking hazards.
"][checkbox value=" -Use of gates.
"][checkbox value=" -Caution around open water.
"][checkbox value=" -Falling.
"][checkbox value=" -Sunscreen if summer.
"][checkbox value=" -Smoke detectors, smoke free environment.
"][checkbox value=" -Lower crib mattress.
"][checkbox value=" -Check window guards.
"][checkbox value=" -Supervise near dogs, lawnmowers, streets, and driveways.
"][checkbox value=" -Burn prevention.
"][checkbox value=" -Tantrums.
"][checkbox value=" -Recommended to eat meals as family.
"][checkbox value=" -Allow toddler to feed self and drink from cup not bottle.
"][checkbox value=" -2 snacks low in sugar daily.
"][checkbox value=" -Avoid choke foods.
"][checkbox value=" -Don't put toddler to bed with bottle.
"][checkbox value=" -Brush teeth daily, use of fluoride.
"][checkbox value=" -Give individual attention.
"][checkbox value=" -Limit but enforce rules.
"][checkbox value=" -Allow no harm to self or things or others.
"][checkbox value=" -Delay toilet training.
"][checkbox value=" -Poison prevention:
-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.
"][comment memo="other specifics" memo_size="small"][checkbox value="-Screened for Tuberculosis Risk (Close contact with person with TB, live in area where TB is common, recent immigrant?) - low risk.
"][checkbox value="-Advised return to clinic at 18 month & 2 years of age, or sooner if needed.
"][/conditional][conditional field="Q1" condition="(Q1).is('2 year')"]-Injury prevention, health promotion issues discussed including age specific guidance:
[comment memo="anticipatory guidance" memo_size="small"][checkbox value=" -Burn prevention
"][checkbox value=" -Care near streets
"][checkbox value=" -Caution around open water
"][checkbox value=" -Use of car seats
"][checkbox value=" -Transition from crib to bed
"][checkbox value=" -Toilet training
"][checkbox value=" -Night terrors and tantrum information
"][comment memo="other specifics" memo_size="small"][checkbox value="-Screened for Tuberculosis Risk (Close contact with person with TB, live in area where TB is common, recent immigrant?) - low risk.
"][checkbox value="-Screened for Lead Poisoning Risk (house older than 1950) - low risk
"][checkbox value="-Advised return to clinic at 3 years of age, or sooner if concerns arise.
"][/conditional][conditional field="Q1" condition="(Q1).is('3 year')"]-Injury prevention, health promotion issues discussed including age specific guidance:
[comment memo="anticipatory guidance" memo_size="small"][checkbox value=" -Burn prevention
"][checkbox value=" -Care near streets
"][checkbox value=" -Caution around open water
"][checkbox value=" -Use of car seats
"][checkbox value=" -Transition from crib to bed
"][checkbox value=" -Use of bike helmet
"][checkbox value=" -Toilet training
"][checkbox value=" -Night terrors and tantrum information
"][comment memo="other specifics" memo_size="small"][checkbox value="-Screened for Tuberculosis Risk (Close contact with person with TB, live in area where TB is common, recent immigrant?) - low risk.
"][checkbox value="-Screened for Lead Poisoning Risk (house older than 1950) - low risk
"][checkbox value="-Advised return to clinic at 4-6 years of age, or sooner if concerns arise
"][/conditional][conditional field="Q1" condition="(Q1).is('4 year')"]-Injury prevention, health promotion issues discussed including age specific guidance:
[comment memo="anticipatory guidance" memo_size="small"][checkbox value=" -Burn prevention (matches)
"][checkbox value=" -Care near streets
"][checkbox value=" -Caution around open water
"][checkbox value=" -Use of appropriate car restraints information reviewed
"][checkbox value=" -Self-esteem issues
"][checkbox value=" -Limit screen time
"][checkbox value=" -Use of helmets when riding bike/scooter
"][comment memo="other specifics" memo_size="small"][checkbox value="-Advised return to clinic in one year or sooner if concerns arise
"][/conditional][conditional field="Q1" condition="(Q1).is('5 year')"]-Injury prevention, health promotion issues discussed including age specific guidance:
[comment memo="anticipatory guidance" memo_size="small"][checkbox value=" -Burn prevention (matches)
"][checkbox value=" -Care near streets
"][checkbox value=" -Caution around open water
"][checkbox value=" -Use of appropriate car restraints information reviewed
"][checkbox value=" -Self-esteem issues
"][checkbox value=" -Limit screen time
"][checkbox value=" -Use of helmets when riding bike/scooter
"][comment memo="other specifics" memo_size="small"][checkbox value="-Vision screening/acuity performed and unremarkable
"][checkbox value="-Hearing screening performed and unremarkable
"][checkbox value="-Hearing screening attempted but child uncooperative
"][checkbox value="-Advised return to clinic in one year or sooner if concerns arise
"][/conditional][conditional field="Q1" condition="(Q1).is('6-10 year')"]
[textarea cols=144 default="#1 Normal growth and development. Injury prevention and health promotion issues discussed."]
[textarea cols=144 default="No immunizations given today/Immunizations given today. Side effects, risks, and benefits of immunizations discussed."]
[textarea cols=144 default="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."][/conditional][conditional field="Q1" condition="(Q1).is('11-14 year')"]
[textarea cols=144 default="#1 Normal growth and development. Injury prevention and health promotion issues discussed."]
[textarea cols=144 default="Immunizations given/No immunizations given today. Side effects, risks, and benefits of immunizations discussed."]
[textarea cols=144 default="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."][/conditional][conditional field="Q1" condition="(Q1).is('15-18 year')"]
[textarea cols=144 default="#1 Normal growth and development. Injury prevention and health promotion issues discussed."]
[textarea cols=144 default="Immunizations given. Side effects, risks, and benefits of immunizations discussed/No immunizations given today."]
[textarea cols=144 default="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."]
[/conditional]-Additional comments: [checkbox value="none"][textarea][link url="https://brightfutures.aap.org/Bright%20Futures%20Documents/BF4_POCKETGUIDE.pdf" memo="
Peds Anticipatory Guidance Guide (AAP)"][link url="https://www.aap.org/en-us/Documents/periodicity_schedule.pdf" memo="
Peds Prev Health Screening Schedule (AAP)"][link url="https://www.cdc.gov/vaccines/schedules/hcp/imz/child-adolescent.html" memo="
Peds Immunizations Schedule (CDC)"]
PHYSICAL EXAM:
coding blurbs
ASSESSMENT/PLAN:
-Additional comments:
Peds Anticipatory Guidance Guide (AAP)

Peds Prev Health Screening Schedule (AAP)

Peds Immunizations Schedule (CDC)

Result - Copy and paste this output:

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