Well Child Check

Chief Complaint: [Capture the major reason for the patient's visit today. If there is more than one, list these in bullet point format.] HPI: [Include a detailed explanation of the child's current health status, including any recent illnesses, developmental concerns, or parental observations. Use numbered bullet points for distinct issues.] Social History: [Include details regarding family structure, daycare/school attendance, home environment, and recent changes.] Growth and Vital Signs: Weight: [Insert weight and percentile] Length/Height: [Insert length/height and percentile] Head Circumference (FOC): [Insert measurement and percentile, if age-appropriate] BMI (if applicable): [Insert BMI and percentile] Blood Pressure (if applicable): [Insert BP] Pulse Oximetry (if applicable): [Insert result] Developmental Assessment: (Only include the section relevant to the child's current age.) 2-5 Days: [Red reflex, nursery screen review, sleep position, crying curve, safe handling.] 2 Weeks: [Red reflex, fix & follow, nursery screen review, maternal PPD screening.] 2 Months: [Head control, social smile, cooing.] 4 Months: [Rolling, reaching, social engagement.] 6 Months: [Sitting with support, babbling, starting solids.] 9 Months: [Speech/language development, sippy cup transition.] 12 Months: [Walking with support, first words, social interaction.] 15-18 Months: [Language and autism screening, vocabulary growth.] 2 Years: [2-word phrases, parallel play, simple commands.] 3-4 Years: [Drawing shapes, counting, following instructions.] 5-10 Years: [School performance, social skills, peer relationships.] 11-14 Years: [HEEADSSS assessment: home, education, activities, drugs, sexuality, safety.] 15-18 Years: [HEEADSSS reassessment: independence, safe behaviors, reproductive health.] Dietary History: [Include current diet, breastfeeding/formula, solids, Vitamin D/iron, milk transition, sippy cup use if applicable.] Review of Systems (This section should not include interpretations by the patient or physician. It should only include subjective signs and symptoms mentioned by the patient.) Constitutional: [Capture any subjective findings reported by the patient regarding this organ system] (If nothing is noted in the transcript, write "No fever, chills, fatigue, or weight changes.") Eyes: [Capture any subjective findings reported by the patient regarding this organ system] (If nothing is noted in the transcript, write "No vision changes, redness, pain, or discharge.") Ears, Nose, Throat: [Capture any subjective findings reported by the patient regarding this organ system] (If nothing is noted in the transcript, write "No hearing loss, tinnitus, nasal congestion, rhinorrhea, sore throat, or dysphagia.") Cardiovascular: [Capture any subjective findings reported by the patient regarding this organ system] (If nothing is noted in the transcript, write "No chest pain, palpitations, or edema.") Respiratory: [Capture any subjective findings reported by the patient regarding this organ system] (If nothing is noted in the transcript, write "No shortness of breath, cough, or wheezing.") Gastrointestinal: [Capture any subjective findings reported by the patient regarding this organ system] (If nothing is noted in the transcript, write "No nausea, vomiting, diarrhea, constipation, or abdominal pain.") Genitourinary: [Capture any subjective findings reported by the patient regarding this organ system] (If nothing is noted in the transcript, write "No dysuria, hematuria, urinary frequency, or urgency.") Musculoskeletal: [Capture any subjective findings reported by the patient regarding this organ system] (If nothing is noted in the transcript, write "No joint pain, stiffness, or swelling.") Skin: [Capture any subjective findings reported by the patient regarding this organ system] (If nothing is noted in the transcript, write "No rashes, lesions, or itching.") Neurologic: [Capture any subjective findings reported by the patient regarding this organ system] (If nothing is noted in the transcript, write "No headaches, dizziness, numbness, or weakness.") Psychiatric: [Capture any subjective findings reported by the patient regarding this organ system] (If nothing is noted in the transcript, write "No anxiety, depression, or mood changes.") Endocrine: [Capture any subjective findings reported by the patient regarding this organ system] (If nothing is noted in the transcript, write "No polyuria, polydipsia, or heat/cold intolerance.") Hematologic/Lymphatic: [Capture any subjective findings reported by the patient regarding this organ system] (If nothing is noted in the transcript, write "No easy bruising, bleeding, or lymphadenopathy.") Allergic/Immunologic: [Capture any subjective findings reported by the patient regarding this organ system] (If nothing is noted in the transcript, write "No allergies, sneezing, or hives.") Physical Exam (Include both normal and abnormal findings explicitly mentioned in the transcript. Use proper, medical terminology. Only include headings for organ systems that are explicitly examined in the transcript. Leave out systems that are not mentioned. Do not include interpretations mentioned by the patient or physician, only objective signs and symptoms. Constitutional: [Capture any objective findings reported by the physician (not the patient) regarding this organ system] Vital Signs: [Capture any objective findings reported by the physician (not the patient) regarding this organ system] [Include specific values if mentioned.] Head: [Capture any objective findings reported by the physician (not the patient) regarding this organ system] Eyes: [Capture any objective findings reported by the physician (not the patient) regarding this organ system] Ears, Nose, Throat: [Capture any objective findings reported by the physician (not the patient) regarding this organ system] Neck: [Capture any objective findings reported by the physician (not the patient) regarding this organ system] Cardiovascular: [Capture any objective findings reported by the physician (not the patient) regarding this organ system] Respiratory: [Capture any objective findings reported by the physician (not the patient) regarding this organ system] Gastrointestinal: [Capture any objective findings reported by the physician (not the patient) regarding this organ system] Genitourinary: [Capture any objective findings reported by the physician (not the patient) regarding this organ system] Musculoskeletal: [Capture any objective findings reported by the physician (not the patient) regarding this organ system] (If specific joints, muscles, tendons, or ligaments are mentioned, create a specific bullet point for them and their exam findings. Be as specific as possible regarding these findings.) (Include the names of specific exam maneuvers and their results if mentioned by the physician.) Skin: [Capture any objective findings reported by the physician (not the patient) regarding this organ system] Neurologic: [Capture any objective findings reported by the physician (not the patient) regarding this organ system] Psychiatric: [Capture any objective findings reported by the physician (not the patient) regarding this organ system] Screenings: [Document screenings: NMS, PPD, anemia, lead, lipid panel, PHQ/GAD, HIV, hearing, vision, autism, scoliosis, as age-appropriate.] Vaccinations: [List vaccines given today or "Up-to-date."] Anticipatory Guidance: [Based on age: sleep safety, car seats, poison control, dental hygiene, screen time, physical activity, reproductive health, etc.] Specialist Care [If patient is seeing any medical specialists, list them here in number list format. Include name and specialty.] Assessment & Plan: Well Child Check Assessment: (Include a detailed assessment the patient's developmental and whether or not they are hitting the appropriate milestones. Also mention any vaccines, labs, or other interventions undertaken during today's visit.) Plan: (Include a bullet point list for the plan with regard to this specific problem. Include all medications related to this problem and any changes in their dosing today. Also include labs, tests, and referrals ordered today. If specific timeframes were discussed, mention these as well. Only include items specifically mentioned by the physician.) 1. [Medical Diagnosis #1] [include the ICD10 code for this diagnosis] Assessment: (Include a detailed assessment of this specific condition in paragraph style.) (State the most likely diagnosis as well as any less likely diagnoses mentioned by the physician in the appointment.) (Include any changes in the condition since prior appointments or with recent interventions.) Plan: (Include a bullet point list for the plan with regard to this specific problem. Include all medications related to this problem and any changes in their dosing today. Also include labs, tests, and referrals ordered today. If specific timeframes were discussed, mention these as well. Only include items specifically mentioned by the physician.) (Continue this pattern of Assessment and Plan for all other medical conditions discussed in today's visit.) Follow-up: [Insert next well visit timeline, e.g., "Return in 3 months."] [Any specific follow-up instructions.] (Never come up with your own patient details, assessment, plan, interventions, evaluation, and plan for continuing care - 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 the information has not been explicitly mentioned in your output, just leave the relevant placeholder or omit the placeholder completely.) (Use as many lines, paragraphs or bullet points, depending on the format, as needed to capture all the relevant information from the transcript.)