Saturday, August 23, 2008

Examination & Write-Up Guidelines

Examination & Write-Up Guidelines 2008 - 2009


SUBJECTIVE
Chief Complaint
Present Illness
Past History (include prenatal, natal and post-natal information)
Allergies
Accidents
Illnesses
Operations
Hospitalizations
Family History
Family Diseases
Social History
Review of Systems
Habits
Diet
Sleep
Elimination
Development


OBJECTIVE General Statement of the Infant / Child
Skin
HEENT
Neck
Nodes
Cardiac Status (include pulses)
Lungs
Abdomen
G.U.
Rectal
Extremities
Neurological Assessment

ASSESSMENT
Well Child Care — Health Supervision Include a statement about growth and development
Minor Acute Illness (i.e. URI, bilateral otitis media, pharyngitis, gastroenteritis)


PLAN
Well Child Care
Immunizations
Any teaching completed in the exam
Minor Acute Illness
State any therapy instituted

NOTE:
Describe what you are seeing in the Objective part of the examination.
Label what you described in the Assessment.

No comments: