Wednesday, July 2, 2008

Idea for Simplified Well Visit Template

So, after two months on Greenway, I think I've formulated what I think would be a good approach to a well-child template. I'll post it here with the first sbulleted response as the default response; the other options would be multiple-select. The idea is that for a normal child, all you would have to do is select the template(s) and sign, so you could do your visit without being glued to the tablet.
So here is my template:
SIMPLIFIED WELL VISIT TEMPLATE
HPI SECTION

GROWTH CHART REVIEW:
• Interval growth is normal.
• Percentiles are: weight (#) %, length (#) %, OFC (#) %, wt/ht (#) %
• Percentiles are: weight (#) %, height (#)%, BMI (#)%
• Growth is concerning because:

CONCERNS:
• There are no concerns today.
• Parent(s) are worried about: ________
• NAME is ill today with ______
• (free text)

PROBLEM LIST REVIEW:
• There are no active problems.
• Active problems are stable.
• Active problems are: (import active problems)

MEDICATIONS
• There are no ongoing medications.
• Medications include: (import active medications)
• Changes in medications since last visit include: (text)

EATING
• (Name) is eating normally for his/her age or developmental level.
• (Name) is nursing every (#) hours.
• (Name) is drinking (formula) (#) ounces every (#) hours.
• (Name) is taking baby foods, stage (#).
• (Name) is eating table foods.
• (Name) is drinking (select type) milk.
• (Name) has excessive calorie intake due to (field).

SLEEPING
• There are no problems with sleeping.
• (Name) is sleeping (#) hours per night.
• (Name) is taking (#) naps per day.
• (Name) is waking (#) time a night.
• (Name) has trouble falling asleep.

DEVELOPMENTAL MILESTONES
• Developmental milestones are appropriate for age in all areas.
• (Name) is not reaching the expected GROSS MOTOR milestones because (field).
• (Name) is not reaching the expected FINE MOTOR milestones because (field).
• (Name) is not reaching the expected LANGUAGE milestones because (field).
• (Name) is not reaching the expected SOCIAL milestones because (field)
• (Name) passed/failed the MCHAT screen for autism.
• Parents are concerned about: (field)

PMFSH:

ROS:
(insert my short ROS admin defaults here)

PE:
(Leave blank; create separate physical exam templates that can be overlayed or can be set as exam types)

DIAGNOSIS:
• (Name) is a healthy (age) (sex) who is growing and developing normally.
• Developmental delay (provide details; or “name” each type (gross motor, etc) but link it to the general DD code)
• List common chronic problems to choose from, such as ADHD, asthma, atopic dermatitis
• List common acute illness diagnoses that would be seen in the course of a well check, such as URI, OM, diaper rash, atopic dermatitis.

PLAN:
(If doing separate templates for each well exam, pre-select the appropriate vaccines; if using a master template, then make separate plan-only templates based on age to select for age-appropriate vaccines and anticipatory guidance, as well as billing codes. I would avoid long checklists on anticipatory guidance, instead using general terms or limiting to one or two things. If there are age-specific templates, they could also include Denver 2 or Bright Futures developmental milestones if desired in the HPI section, although I prefer a generic “normal development” statement.)


What are your suggestions/comments?

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