WELL CHILD/6 to 9 MONTHS MR - dchealthcheck.net · WELL CHILD/6 to 9 MONTHS Referrals Assessment...
Transcript of WELL CHILD/6 to 9 MONTHS MR - dchealthcheck.net · WELL CHILD/6 to 9 MONTHS Referrals Assessment...
WELL CHILD/6 to 9 MONTHS
Referrals
Assessment and Plan
Physical Examination (Unclothed)
No. 3 of 7
MR #: __________________________
NL ABN
❏ ❏ General Appearance _______________________________________________
❏ ❏ Head / Fontanelle _________________________________________________
❏ ❏ Eyes / Red Reflex _________________________________________________
❏ ❏ Ears ____________________________________________________________
❏ ❏ Nose ___________________________________________________________
❏ ❏ Mouth/Throat, and Teeth ____________________________________________
❏ ❏ Lungs ___________________________________________________________
❏ ❏ Heart / Pulses ____________________________________________________
❏ ❏ Abdomen ________________________________________________________
❏ ❏ Genitalia _________________________________________________________
❏ ❏ Extremities / Hips __________________________________________________
❏ ❏ Back ____________________________________________________________
❏ ❏ Skin_____________________________________________________________
❏ ❏ Neurologic _______________________________________________________
_______________________________________________________________________
❏ Well Child ❏ Additional concerns or identified special health needs (detail below):
❏ Dev Delay ❏ Seizure(s) ❏ Wheezing/RAD ❏ Dental ❏ Other:
Assessment: ____________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
Plan:___________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
❏ Education handouts and/or plan reviewed with patient/parent, who verbalizes understanding
❏ Referral Made: ________________________________________________________
F/U Next Visit: ____________________________________________________________
Instructions: If the action was taken or completed, the open box must be marked (❏ or ❏ ).x✔
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 #% % %❏ lb.
❏ kg.❏ in.❏ cm.
❏ in.❏ cm.
History and physical reviewed with resident at time of visit, agree with the diagnosisof and treatment
Provider Print Signature
Nurse Print Signature
Other Print Signature
Version 1.1 (5/06)
History/Parent Concerns
Social/Family History
Review of Systems
Anticipatory Guidance Provided
Immunizations/Screens
Interval History: ❏ None ❏ Newborn History Previously Taken
_________________________________________________________________
_________________________________________________________________
Current Medications: _______________________________________________
_________________________________________________________________
❏ Completed ____________________________________________________
________________________________________________________________
________________________________________________________________
Child Care: ❏ Yes ❏ No Type: __________________________________
❏ 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:________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
❏ Topics discussed and/or handout given SUGGESTED AGE APPROPRIATE TOPICS ARE ON THE BACK
Anemia Screen (HGB/HCT): ❏ Ordered ❏ Deferred until 1 year
Lead Risk: ❏ No ❏ Yes If, yes: ❏ Test Ordered
❏ Immunizations Reviewed
Immunizations Ordered: ❏ Rotavirus
❏ DTaP ❏ IPV ❏ HIB ❏ HBV
❏ HIB/HBV ❏ DTAP/IPV/HBV ❏ PCV7 ❏ Influenza
❏ Medical / Religious Exemptions: ___________________________________
Immunization Comments: ____________________________________________
_________________________________________________________________
COPY FOR DC DOH
WELL CHILD/6 to 9 MONTHS
Referrals
Assessment and Plan
Physical Examination (Unclothed)
No. 3 of 7
MR #: __________________________
NL ABN
❏ ❏ General Appearance _______________________________________________
❏ ❏ Head / Fontanelle _________________________________________________
❏ ❏ Eyes / Red Reflex _________________________________________________
❏ ❏ Ears ____________________________________________________________
❏ ❏ Nose ___________________________________________________________
❏ ❏ Mouth/Throat, and Teeth ____________________________________________
❏ ❏ Lungs ___________________________________________________________
❏ ❏ Heart / Pulses ____________________________________________________
❏ ❏ Abdomen ________________________________________________________
❏ ❏ Genitalia _________________________________________________________
❏ ❏ Extremities / Hips __________________________________________________
❏ ❏ Back ____________________________________________________________
❏ ❏ Skin_____________________________________________________________
❏ ❏ Neurologic _______________________________________________________
_______________________________________________________________________
❏ Well Child ❏ Additional concerns or identified special health needs (detail below):
❏ Dev Delay ❏ Seizure(s) ❏ Wheezing/RAD ❏ Dental ❏ Other:
Assessment: ____________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
Plan:___________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
❏ Education handouts and/or plan reviewed with patient/parent, who verbalizes understanding
❏ Referral Made: ________________________________________________________
F/U Next Visit: ____________________________________________________________
Instructions: If the action was taken or completed, the open box must be marked (❏ or ❏ ).x✔
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 #% % %❏ lb.
❏ kg.❏ in.❏ cm.
❏ in.❏ cm.
History and physical reviewed with resident at time of visit, agree with the diagnosisof and treatment
Provider Print Signature
Nurse Print Signature
Other Print Signature
Version 1.1 (5/06)
History/Parent Concerns
Social/Family History
Review of Systems
Anticipatory Guidance Provided
Immunizations/Screens
Interval History: ❏ None ❏ Newborn History Previously Taken
_________________________________________________________________
_________________________________________________________________
Current Medications: _______________________________________________
_________________________________________________________________
❏ Completed ____________________________________________________
________________________________________________________________
________________________________________________________________
Child Care: ❏ Yes ❏ No Type: __________________________________
❏ 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:________________________________________________________
_________________________________________________________________
_________________________________________________________________
_________________________________________________________________
❏ Topics discussed and/or handout given SUGGESTED AGE APPROPRIATE TOPICS ARE ON THE BACK
Anemia Screen (HGB/HCT): ❏ Ordered ❏ Deferred until 1 year
Lead Risk: ❏ No ❏ Yes If, yes: ❏ Test Ordered
❏ Immunizations Reviewed
Immunizations Ordered: ❏ Rotavirus
❏ DTaP ❏ IPV ❏ HIB ❏ HBV
❏ HIB/HBV ❏ DTAP/IPV/HBV ❏ PCV7 ❏ Influenza
❏ Medical / Religious Exemptions: ___________________________________
Immunization Comments: ____________________________________________
_________________________________________________________________
WELL CHILD/6 to 9 MONTHSADDITIONAL 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 REGISTRY, POST OFFICE BOX 77498WASHINGTON, DC 20013-7749
FAX: (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
6 Months
9 Months
__ Reaches for objects
__ Pincer grasp
__ Babbles__ Turns to voice__ Imitates sounds
__ Responds to name__ Jabbers__ Dada/Mama (nonspecific)__ Waves bye-bye
__ Feeds self__ Works for toy
__ Peekaboo__ Stranger anxiety
■ NUTRITION• Breastfeeding• Vitamins• Formula• No juice• Solid foods/finger foods
- May start rice cereal- Introduce only 1 solid food
every week• Safe foods/avoid choking• Elimination• Review of WIC status
At 9 months:• Transition cup• No cow’s milk
■ ORAL HEALTH• Clean teeth, gums (water only)• No bottle in crib
■ IMMUNIZATIONS EXPLAINED■ INFANT CARE
• Skincare• Good sleep habits• Thermometer training
■ BEHAVIOR & DEVELOPMENT■ PARENT-INFANT INTERACTION
• Temperament• Talk/read/sing to baby• Parental depression• Sibling rivalry• Family relationships• Simple rules/limits• Stranger anxiety
■ INJURY AND ILLNESS PREVENTION• Crib safely • Child safety seat• Falls• Burns• Water heater• Smoke detectors• Violence/guns• Childproofing• Electrical outlets/cords• No walkers• Back to sleep• Passive smoking• Lead risks (> 10 ug/dL, high
risk)• Limit TV
• Sun safety• Water safety
Suggested age appropriate topics for anticipatory guidance:
x✔
__ Sits briefly__ Roll back to front
__ Pulls to stand__ Stands holding on__ Gets to sitting