mr #: well child/0 to 1 month€¦ · well child/0 to 1 month birth history/parent concerns...
Post on 10-Oct-2020
1 Views
Preview:
TRANSCRIPT
WELL CHILD/0 to 1 MONTH
Birth History/Parent Concerns
Social/Family History
Review of Systems
Anticipatory Guidance Provided
Immunizations/Screens Referrals
Assessment and Plan
Physical Examination (Unclothed)
No. 1 of 7
MR #: __________________________
❏ Completed
Pregnancy (medication, illnesses, drugs, ETOH) _________________________
________________________________________________________________
________________________________________________________________Gestational age: ___________ BW: ___________ APGARS: _______________
Complications: ____________________________________________________
________________________________________________________________
❏ Completed ____________________________________________________
________________________________________________________________
________________________________________________________________
Child Care: ❏ Yes ❏ No Type: __________________________________
NL ABN
❏ ❏ General Appearance _______________________________________________
❏ ❏ Head / Fontanelle _________________________________________________
❏ ❏ Eyes / Red Reflex _________________________________________________
❏ ❏ Ears ____________________________________________________________
❏ ❏ Nose ___________________________________________________________
❏ ❏ Mouth/Throat _____________________________________________________
❏ ❏ Lungs ___________________________________________________________
❏ ❏ Heart / Pulses ____________________________________________________
❏ ❏ Abdomen ________________________________________________________
❏ ❏ Genitalia _________________________________________________________
❏ ❏ Extremities / Hips __________________________________________________
❏ ❏ Back ____________________________________________________________
❏ ❏ Skin_____________________________________________________________
❏ ❏ Neurologic _______________________________________________________
_______________________________________________________________________❏ Nutrition Assessed: ❏ Breastfed ❏ Formula _________________
_________________________________________________________________
❏ Elimination Assessed ____________________________________________
❏ Environment Assessed __________________________________________
❏ Sleep Patterns Assessed ________________________________________
❏ Development Assessed: (Use Table on Back) ________________________
OR ❏ DENVER DEVEL. II ADMINISTERED
OR ❏ OTHER TOOL ADMINISTERED: ________________________________
Comments:________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
❏ Well Child ❏ Additional concerns or identified special health needs (detail below):
❏ Hearing Concern ❏ Prematurity ❏ Other:
Assessment: ____________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
Plan:___________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
❏ Education handouts and/or plan reviewed with patient/parent, who verbalizes understanding
❏ Topics discussed and/or handout given SUGGESTED AGE APPROPRIATE TOPICS ARE ON THE BACK
❏ Referral Made: _______________________________________________________
F/U Next Visit: ___________________________________________________________
Newborn Metabolic Screen: ❏ Pending ❏ NL ❏ ABN ____________
Newborn Hearing Screening: ❏ Pending ❏ Pass ❏ Fail
❏ Immunizations Reviewed: ❏ First HBV given Date:_________________
Immunizations Ordered:
❏ HBV
❏ Medical / Religious Exemptions: ___________________________________
Immunization Comments: ____________________________________________
_________________________________________________________________
DRUG ALLERGIES
WEIGHT
IFINDICATED:
PULSE Ox TEMP BPRR P
HEIGHT HEAD CIRC.
NAME
ACCOMPANIED BY PHONE 1 PHONE 2
AGE
YRS MOS
DOB ❏ M
❏ F
❏ 1st Visit ❏ Periodic Visit
DATE/TIME INSURANCE ID #% % %
Instructions: If the action was taken or completed, the open box must be marked (❏ or ❏ ).x✔
History and physical reviewed with resident at time of visit, agree with the diagnosis of and treatment
Provider Print Signature
Nurse Print Signature
Other Print Signature
❏ lb.❏ kg.
❏ in.❏ cm.
❏ in.❏ cm.
Version 1.1 (5/06)
COPY FOR DC DOH
WELL CHILD/0 to 1 MONTH
Birth History/Parent Concerns
Social/Family History
Review of Systems
Anticipatory Guidance Provided
Immunizations/Screens Referrals
Assessment and Plan
Physical Examination (Unclothed)
No. 1 of 7
MR #: __________________________
❏ Completed
Pregnancy (medication, illnesses, drugs, ETOH) _________________________
________________________________________________________________
________________________________________________________________Gestational age: ___________ BW: ___________ APGARS: _______________
Complications: ____________________________________________________
________________________________________________________________
❏ Completed ____________________________________________________
________________________________________________________________
________________________________________________________________
Child Care: ❏ Yes ❏ No Type: __________________________________
NL ABN
❏ ❏ General Appearance _______________________________________________
❏ ❏ Head / Fontanelle _________________________________________________
❏ ❏ Eyes / Red Reflex _________________________________________________
❏ ❏ Ears ____________________________________________________________
❏ ❏ Nose ___________________________________________________________
❏ ❏ Mouth/Throat _____________________________________________________
❏ ❏ Lungs ___________________________________________________________
❏ ❏ Heart / Pulses ____________________________________________________
❏ ❏ Abdomen ________________________________________________________
❏ ❏ Genitalia _________________________________________________________
❏ ❏ Extremities / Hips __________________________________________________
❏ ❏ Back ____________________________________________________________
❏ ❏ Skin_____________________________________________________________
❏ ❏ Neurologic _______________________________________________________
_______________________________________________________________________❏ Nutrition Assessed: ❏ Breastfed ❏ Formula _________________
_________________________________________________________________
❏ Elimination Assessed ____________________________________________
❏ Environment Assessed __________________________________________
❏ Sleep Patterns Assessed ________________________________________
❏ Development Assessed: (Use Table on Back) ________________________
OR ❏ DENVER DEVEL. II ADMINISTERED
OR ❏ OTHER TOOL ADMINISTERED: ________________________________
Comments:________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
❏ Well Child ❏ Additional concerns or identified special health needs (detail below):
❏ Hearing Concern ❏ Prematurity ❏ Other:
Assessment: ____________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
Plan:___________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
❏ Education handouts and/or plan reviewed with patient/parent, who verbalizes understanding
❏ Topics discussed and/or handout given SUGGESTED AGE APPROPRIATE TOPICS ARE ON THE BACK
❏ Referral Made: _______________________________________________________
F/U Next Visit: ___________________________________________________________
Newborn Metabolic Screen: ❏ Pending ❏ NL ❏ ABN ____________
Newborn Hearing Screening: ❏ Pending ❏ Pass ❏ Fail
❏ Immunizations Reviewed: ❏ First HBV given Date:_________________
Immunizations Ordered:
❏ HBV
❏ Medical / Religious Exemptions: ___________________________________
Immunization Comments: ____________________________________________
_________________________________________________________________
DRUG ALLERGIES
WEIGHT
IFINDICATED:
PULSE Ox TEMP BPRR P
HEIGHT HEAD CIRC.
NAME
ACCOMPANIED BY PHONE 1 PHONE 2
AGE
YRS MOS
DOB ❏ M
❏ F
❏ 1st Visit ❏ Periodic Visit
DATE/TIME INSURANCE ID #% % %
Instructions: If the action was taken or completed, the open box must be marked (❏ or ❏ ).x✔
History and physical reviewed with resident at time of visit, agree with the diagnosis of and treatment
Provider Print Signature
Nurse Print Signature
Other Print Signature
❏ lb.❏ kg.
❏ in.❏ cm.
❏ in.❏ cm.
Version 1.1 (5/06)
WELL CHILD/0 to 1 MONTHADDITIONAL COMMENTS: ________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
NURSING NOTES: PAIN? ❏ No ❏ Yes Score ____________________
❏ Management: See Treatment Plan
Interpreter Used? ❏ Yes ❏ No Primary Language:________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
INSTRUCTIONSIf the action was taken or completed, the open box must be marked (❏ or ❏).
If the child is enrolled in Medicaid, please be sure to print and sign your name in the space provided and fax or mail the completed form to:
HEALTHCHECK REGISTRYPOST OFFICE BOX 77498
WASHINGTON, DC 20013-7749FAX: (202) 541-5907
For further information on HealthCheck or Bright Futures go to www.brightfutures.org/healthcheck.html
BEHAVIOR AND DEVELOPMENT
Age Gross Motor Fine Motor Communication Social
0 to 1Month
__ Lifts head when prone__ Equal Movements
__ Follows object with eyes
__ Vocalizes__ Responds to stimuli
__ Smiles spontaneously
__ Looks at face
■ NUTRITION• Breastfeeding• Formula• No solid food
(wait until 4-6 mos)• Elimination• No honey• Review of WIC status
■ ORAL HEALTH• No bottle in crib
■ IMMUNIZATIONS EXPLAINED
■ INFANT CARE• Skincare/bathing• Thermometer use• Good sleep habits
■ BEHAVIOR & DEVELOPMENT■ PARENT-INFANT INTERACTION
• Parental depression• Talk/read/sing to baby• Holding/cuddling• Temperament
■ INJURY AND ILLNESS PREVENTION• Crib safety • Back to sleep• Child safety seat• Falls• Burns• Water heater• Smoke detectors• Sun safety• Violence/guns• Passive smoking• Never shake baby
Suggested age appropriate topics for anticipatory guidance:
x✔
top related