18 MONTH VISIT

OVERALL_INSTRUCTIONS

Write in bullet format

Template

AGE [age] MEDHX: [Provide the patient's past medical history very briefly, and any current problems, in bullet point form.] 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: [Document any concerns raised during the visit. If no concerns, state, "Feeding well, wide variety of foods, all food groups, Drinking «[milk_type]», «<[amount]> oz» per day «Limited junk foods or sugary drinks,» «no feeding issues»] ROS: [Document where and how patient is sleeping, whether or not parents have started brushing patient's teeth and that they have been counselled to use fluoridated toothpaste. Document whether bottles are still being used and that weaning bottles was discussed, document whether pacifier is being used] SH: [Detail on social history] DEVELOPMENT: [Nipissing reviewed, no issues] EXAM: [Vitals: Ht: [height] HC: [head_circumference] Wt: [weight] [Keep the exam findings as written below unless otherwise stated for each system] GEN - well appearing, no distress, HEENT - mmm, conjunctivae normal, TMs clear b/l, 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 [sex] genitalia, testes desc. bilaterally (if male patient) MSK - joints normal, moving all extremities spontaneously NEU - good tone, walking independently SKIN - intact, no rashes, no hemangioma ASSESSMENT & PLAN: [Healthy 18 month old infant, «good growth & development» Anticipatory guidance provided in regards to: «Car seat safety»«No OTC cough/ cold medicine, Fever advice/ thermometers», «reading/book exploration, limit screen time», «Discipline/ Parenting skills programs», «Socializing/ peer play opportunities», «Wean from pacifier, Dental care/ Dentist», «Toilet learning»] ISSUES/CONCERNS: [Document any issues or concerns identified during the visit. If there are no issues, state "No issues or screening."] VACCINES «DPTP-Hib» «& Influenza» FOLLOW UP @ 2 years old