Follow-Up Report

Chief Complaint

[reason for follow-up]

specialty

Pediatrics

tags

Template

It was a pleasure to see [name] today as a follow up for the following issues: [ issues]. This report is composed by Dr. Merchant, and it is generated by voice recognition software. Transcription errors may occur. If one has any concern regarding accuracy, we will be pleased to clarify. Reason for follow up: Problem History: [issues such as Anorexia, ADHD] Active Medications: [drug_name] [dosage] [frequency] [duration] [refils at [number] day intervals] Active concerns: [name] is on [drug_name] [dosage]. [Document any effects and side effects of the medication]. [[pronoun] is drinking [number] can of boost daily]. [No particular activity.] [[pronoun] focus is good and sleep is good.] Investigations: Physical Exam: Weight: [weight] Height: [height] BP: [number] HR: [number] bpm HEENT - [TM normal, neck supple, mmm, pharynx clear, no LAN] RESP - [clear bilat, no LAN, neck supple, mmm] CVS - [normal S1 and S2, no murmurs, good cap refill] ABD - [soft, non-tender, no hsm, no masses] MSK - [normal ROM, no joint swelling] CNS - [grossly normal] DERM - [no rash] Discussion: [[name] is doing well with [drug_name] [dosage].] [We will continue with same dosage.] [There is a lot of room to go up if required-upto [number].] [[pronoun] weight I believe has room for catchup.] [The gain we have seen is catch up not growth at this age.] [[pronoun] is turning [age] soon and hence I will be discharging [pronoun] from my practice.] Impression & Plan [[name] has [number] months prescription of [drug_name].] [disposition/follow-up] Thank you for following this patient with us. We will keep you updated.