Paediatrician-Vorlage
Paediatric Template WHTH
Eine professionelle Paediatrician-Vorlage für medizinisches Fachpersonal.
Über diese Vorlage
Looking for a comprehensive paediatric assessment template? This Paediatric Template WHTH is designed for paediatricians to efficiently document patient encounters. It covers essential areas like reason for referral, history of symptoms, developmental milestones, and examination findings. This template helps streamline the note-taking process, ensuring all critical information is captured. With Heidi, this template can be automatically populated from your visit transcript, saving you time and improving the accuracy of your clinical documentation. This template is ideal for paediatricians seeking a structured and thorough approach to patient notes.
Vorlagenvorschau
**Reason for referral**:
Concern regarding delayed speech development.
**Persons present during appointment**:
Patient, mother, and father.
**History of Symptoms**:
Patient has demonstrated limited verbal communication skills. First words were spoken at 18 months, but vocabulary has not expanded significantly. No history of regression. Hearing tests were performed and were normal. No previous interventions trialled.
**Discussion with Family/Patient**:
Parents expressed concerns about the child's ability to communicate with peers. Reassured parents that early intervention can be beneficial and that further assessment is needed.
**Past Medical history including Birth History**:
Born at 39 weeks gestation via spontaneous vaginal delivery. Birth weight 7lbs 8oz. No complications during delivery. No significant past medical history. No previous surgeries.
**Medication History**:
No current medications or herbal supplements.
**Developmental History**:
Sat up at 6 months, walked at 12 months. Currently able to follow simple instructions. Limited vocabulary, uses gestures to communicate needs.
**Family and Social History**:
No family history of speech or language disorders. Lives at home with both parents and a younger sibling. Attends nursery three days a week.
**Summary of Previous Investigations**:
Hearing test performed at 18 months, results were normal.
**Examination**:
Weight: 12kg, Height: 85cm, HR: 100 bpm, RR: 22, Temp: 37.0C. Alert and interactive. Speech assessment revealed a limited vocabulary of approximately 10 words. Able to follow simple instructions. No other abnormalities noted.
**Impression**:
Delayed speech development. Possible speech delay.
**Plan**:
Referral to speech and language therapy. Schedule follow-up appointment in 3 months. Provide parents with resources on speech development.
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