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?
No comments:
Post a Comment