Well Child Check

Finished note

Example — generated by Notat from a sample visit

Reason for visit:
Follow-up for a persistent cough and reduced energy over the past 10 days.

Assessment:
Symptoms are improving. No red flags identified during today's review.

Plan:
Continue supportive care, review worsening symptoms, and follow up if symptoms do not settle as expected.

Clinical documentation:
Relevant symptoms, meaningful negatives, assessment, and follow-up advice were captured from the sample visit and organised into the selected template.

FactsContext™

Template

 Well Child Check: [create a title for the visit that summarizes the findings and plan in a few words]
Potential ICD-9 codes: V20.2 (routine infant or child health check, [suggest possible ICD-9 codes given the diagnosis or differential diagnosis]

Well Child Check - Baby Record: [summarize findings and plan]

(use "- " to indicate list items, and, if necessary, use "-- " to indicate sub-items in lists)

Medical History: 
- Current age: [give the patients age]
- [Past medical history] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
- [Current medical conditions] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
- [Medications] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
- [Allergies] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)

Parental concerns: 

Growth: [mention how the patient is progressing according to growth charts] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)

Nutrition:
- [Feeding method (breastfeeding, formula, solids)] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
- [Feeding frequency and amount] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
- [Any feeding difficulties] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
- [Any other information discussed regarding nutrition and/or feeding]

Education and Advice:
- [any education and advice given e.g. injury prevention, behaviour, parental fatigue/depression, environmental health, etc.]

Development:
- [anything discussed regarding normal development, e.g. language, movement, walking, etc.]

Physical Examination:
- [include physical exam, e.g. fontanelles, red eye reflex, corneal light reflex, heart/lungs/abdomen, hip exam, etc.]

Investigations/Screening:
- [any planned investigations; if not are discussed state "none currently indicated"]

Immunizations:
- [immunizations received] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
- [Upcoming immunizations] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)

Plan:
- [Follow-up appointments] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
- [Referrals to specialists] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
- [Any other management plan not mentioned previously]