12 MONTH VISIT

OVERALL_INSTRUCTIONS

Use bullet points throughout

Template

AGE [age] MEDHX: [Provide the patient's past medical history and any current problems, concisely.] Attended by: [Specify who attended the visit, e.g., parent, caregiver, etc.] CONCERNS: [Document any concerns raised during the visit. If there are no concerns, state "No concerns."] FEEDING AND ELIMINATION: [Provide a summary of the patient's feeding habits, including the variety of foods consumed and any specific food groups. Discuss any transitions in feeding, such as moving to milk or using a cup or sippy cup, and mention any restrictions on sugary drinks or junk foods. Note any feeding issues or lack thereof. Summarize the patient's voiding and stooling patterns, including any issues such as constipation.] ROS: [[Provide a review of systems, including sleep, teeth, and other relevant areas.] For example: Sleep: [Details about sleep patterns, e.g., "sleeping well, through the night"] Teeth: [Details about dental care, e.g., "brushing discussed"]] SH: [Include any relevant social history information.] DEVELOPMENT: [Provide a detailed summary of the developmental milestones achieved by the patient. Include assessments such as the Nipissing review, responsiveness to name, comprehension of simple requests, language development (e.g., combining sounds, using words), motor skills (e.g., pulling to stand, walking with support, cruising, taking independent steps), fine motor skills (e.g., manipulating objects, pincer grasp), emotional expressions, and social interactions (e.g., playing games, seeking comfort).] EXAM: [[Document the findings of the physical examination, including vitals and system-specific observations.] Vitals: Ht: [height] HC: [head_circumference] Wt: [weight] [document any specific captured abnormal findings on physical exam findings in addition to the following] GEN - well appearing, no distress, HEENT - mmm, conjunctivae normal, TMs clear b/l, pharynx clear neck supple, no signif. lad, CVS - normal S1/S2, good pulses, cap refill<2s RESP - clear B/L, no wheeze/crackles, good air entry B/L, no retractions/tachypnea GI - abdomen soft, NT/ND, no HSM, no masses GU normal patSex genitalia, testes descended bilaterally (if appropriate) MSK - joints normal, moving all extremities spontaneously NEU - good tone, sits well, pivots, bears weight on legs SKIN - intact, no rashes, no hemangioma ASSESSMENT & PLAN: [ [Provide a summary of the patient's current health status, including growth and development milestones. Include anticipatory guidance on diet advancement, introduction of cow's milk, and safety measures such as car seat safety, carbon monoxide/smoke detectors, hot water/bath safety, and electric plug/cord safety. Discuss fall prevention, choking hazards, and safe toys. Offer advice on over-the-counter medications, fever management, and the use of thermometers. Encourage reading and book exploration while advising on limiting screen time.] For example: Assessment: [Details, e.g., "Healthy 12-month-old infant, good growth & development"] Plan: [Anticipatory guidance provided in regards to advancing diet, introducing cow's milk, car seat safety (rear facing until age 2 recommended by AAP),Carbon monoxide/ Smoke detectors, «\Hot water < 49C/ bath safety, Electric plugs/ cords, Falls/ stairs/ no walkers,Choking/ safe toys, No OTC cough/ cold medicine, Fever advice/ thermometers», «reading/book exploration, limit screen time]] ISSUES/CONCERNS: [Document any issues or concerns identified during the visit. If there are no issues, state "No issues or screening."] VACCINES: [List each vaccine administered to the patient. Use a comma-separated format to list the vaccines, ensuring clarity and consistency. Include details such as the vaccine name and any relevant notes if applicable.] FOLLOW UP @ 15 months: