241101 John Doe
cc: Dr. Emily Smith
Head to Toe Assessment
General Appearance: John appeared alert and active, with appropriate posture and body movements for his age. He interacted well with his caregivers and the examiner, showing developmental behaviors typical for a 5-year-old.
Vital Signs: John's temperature was 37.2°C, heart rate 98 bpm, respiratory rate 22 breaths per minute, blood pressure 90/60 mmHg, and oxygen saturation 98%. All values were within age-appropriate norms.
Head, Face, and Neck: John's head shape was normal with no swelling or masses. His neck was mobile, and lymph nodes were not palpable.
EENT
Eyes: Eyelids were symmetrical, sclera white, conjunctiva clear, pupils equal and reactive to light, and extraocular movements were intact.
Ears: External ears were well-aligned with no discharge. Tympanic membranes appeared normal, and he responded appropriately to sound.
Nose and Sinuses: Nasal patency was good with no discharge. Septum was midline, and there was no sinus tenderness.
Mouth and Throat: Lips, tongue, and gums were healthy. Teeth were erupting as expected, and mucous membranes were moist. Tonsils were not enlarged.
Thorax:
Respiratory: Respiratory rate was regular with no use of accessory muscles. Breath sounds were clear bilaterally.
Cardiac: Heart rate was regular with no murmurs. Peripheral pulses were strong, and capillary refill was less than 2 seconds.
Abdomen: Abdomen was soft with normal bowel sounds. No tenderness or masses were noted.
Extremities and Musculoskeletal: Symmetrical limb movements with full range of motion. No swelling or deformities observed.
Skin: Skin was warm and dry with no rashes or lesions. Birthmarks were noted but not concerning.
Neurological: John was conscious and responsive. Reflexes were appropriate for age, and gross motor skills were developing well.
School Progress: John's teacher, Mrs. Green, reported that he is doing well academically but sometimes struggles with focus. His parents noted that stimulant medication has helped him maintain attention throughout the school day.
Home Progress: At home, John is generally well-behaved but occasionally shows signs of anxiety. His parents, Mr. and Mrs. Doe, mentioned that he completes his homework with some assistance and enjoys extracurricular activities.
Allied therapies and external supports: John attends speech therapy once a week with Ms. Brown at Speech Solutions. The goal is to improve his articulation.
Mood and Mental Health: John's mood is generally positive, though he sometimes expresses anxiety about school. His parents are supportive and attentive to his needs.
Sleep and Diet: John sleeps approximately 10 hours per night and has a balanced diet. His parents ensure he eats a variety of foods.
Side Effects of Medications: No side effects from medication have been reported by John or his parents.
Examination
Weight – 20 kg
Height – 110 cm
BMI – 16.5 kg/m2
BP - 90/60 mmHg
John's physical examination was unremarkable, with all findings within normal limits for his age.
Summary: John is a healthy 5-year-old boy with mild anxiety and focus issues managed with medication and therapy.
Plan:
- Continue current medication and therapy.
- Follow up in 3 months to reassess focus and anxiety levels.
[YYMMDD] (write date of consult in yymmdd formate) [Patient's Name]
cc: [General Practitioner's Name]
Head to Toe Assessment
General Appearance:
[Enter a brief description of the child's general appearance and behaviour] (include only if assessed. Describe level of alertness, activity, posture, body movements, comfort level, and interactions with caregivers or examiner. Comment on developmental appropriateness of behaviour for the child’s age. Write as a paragraph in full sentences.)
Vital Signs:
[Enter the child’s vital signs] (include only if measured. Provide temperature, heart rate, respiratory rate, blood pressure, oxygen saturation, and pain score. Comment on whether values are within age-appropriate norms and note any irregularities or concerns. Write in full sentences using clinical language.)
Head, Face, and Neck: [Enter findings from assessment of the head, face, and neck] (include only if assessed. Comment on head shape, fontanelle status (if age-appropriate), facial symmetry, neck mobility, presence of swelling or masses, and lymph node palpation. Describe findings in full sentences, integrating developmental considerations where relevant.)
EENT
Eyes: [Enter findings from eye examination] (include only if assessed. Describe eyelid position, sclera, conjunctiva, pupil size and reaction, extraocular movements, visual tracking or fixation (according to age), and red reflex if performed. Write in full sentences.)
Ears: [Enter findings from ear inspection and assessment] (include only if assessed. Document external ear shape, alignment, presence of discharge, ear canal condition, tympanic membrane appearance, and auditory responses appropriate for age. Include response to sound if hearing screening is informal. Write in paragraph format.)
Nose and Sinuses: [Enter findings from nasal and sinus assessment] (include only if assessed. Describe nasal patency, discharge, septum alignment, mucosal appearance, and tenderness over sinuses if applicable. Use complete sentences.)
Mouth and Throat: [Enter findings from inspection of oral cavity and throat] (include only if assessed. Comment on lips, tongue, gums, teeth (or eruption pattern), mucous membranes, tonsils, uvula, and palate. Note hydration status and signs of oral lesions or infection. Write as a full paragraph.)
Thorax:
Respiratory: [Enter findings from respiratory assessment] (include only if assessed. Describe respiratory rate, pattern, effort, use of accessory muscles, breath sounds, symmetry of chest movement, and presence of any adventitious sounds such as wheezes or crackles. Include oxygen saturation if measured. Use complete clinical sentences.)
Cardiac: [Enter findings from cardiovascular assessment] (include only if assessed. Document heart rate, rhythm, presence of murmurs, location of point of maximal impulse, peripheral perfusion, capillary refill, and peripheral pulses. Describe in paragraph form using age-appropriate clinical expectations.)
Abdomen: [Enter findings from abdominal assessment] (include only if assessed. Include contour, bowel sounds, tenderness, masses, hepatosplenomegaly, and umbilical condition if applicable. For infants, note umbilical hernia or stump status. Use full sentences.)
Extremities and Musculoskeletal: [Enter findings from limb and joint assessment] (include only if assessed. Comment on symmetry, range of motion, tone, strength, reflexes, presence of swelling or deformities, and gross motor function. Include posture and gait for ambulatory children. Write in full sentences.)
Skin: [Enter findings from skin inspection] (include only if assessed. Describe colour, turgor, temperature, presence of rashes, lesions, bruising, birthmarks, or signs of infection. Note healing wounds or pressure injuries if present. Use paragraph format with objective language.)
Neurological: [Enter findings from neurological assessment] (include only if assessed. Describe level of consciousness, responsiveness, tone, reflexes, gross motor skills, coordination, and developmental milestones relevant to the child’s age. Include cranial nerve observations if performed. Write as a structured paragraph.)
School Progress:
[Summary of patient's school progress and challenges] (comment on efficacy of stimulant medication throughout the school day where applicable) (comment on any behavioural challenges, suspensions, aggression, anxiety at school if applicable) (Comment on any learning supports being received if applicable) (write in full sentence format in paragraphs) (use the patient and parents names to identify who said what or who observed what in the consult) (do not write each point as a list) (write information as a paragraph)
Home Progress:
[Summary of patient's home life and any relevant issues] (write in full sentence format in paragraphs) (use the patient and parents names to identify who said what or who observed what in the consult) (comment on any aggression, anxiety if applicable) (comment on ability to complete homework in the afternoon or extracurricular activities if applicable) (comment on parental stress if applicable) (do not write each point as a list) (write information as a paragraph)
Allied therapies and external supports:
(comment on use of allied therapists including physiotherapy, OT, Speech path, dietician, psychologist where applicable) (Comment on frequency of visits, goals of therapy, name of therapist and company used) (do not write each point as a list) (write information as a paragraph)
Mood and Mental Health:
[Assessment of patient's mood and mental health] (write in full sentence format in paragraphs) (use the patient and parents names to identify who said what or who observed what in the consult) (do not write each point as a list) (write information as a paragraph) (where applicable)
Sleep and Diet:
[Assessment of patient's sleep patterns and dietary habits] (write in full sentence format in paragraphs) (use the patient and parents names to identify who said what or who observed what in the consult) (do not write each point as a list) (write information as a paragraph)
Side Effects of Medications:
[Report on any side effects experienced by the patient] (write in full sentence format in paragraphs) (use the patient and parents names to identify who said what or who observed what in the consult) (do not write each point as a list) (write information as a paragraph)
Examination
Weight – [Weight in kg]
Height – [Height in cm]
BMI – [BMI in kg/m2]
BP - [BP in mmHg]
[Summary of physical examination findings] (write in full sentence format in paragraphs)
Summary:
[Summary of patient's current condition]
Plan:
- [List the outline of the treatment plan, including any medication adjustments and follow-up]
(Never come up with your own patient details, developmental observations, findings, or interpretations – use only the transcript, contextual notes, or clinical note as a reference for the information included in your note. If any information related to a placeholder has not been explicitly mentioned in the transcript, contextual notes, or clinical note, you must not state that the information has not been mentioned – just leave the relevant placeholder or omit the paragraph completely.)
