Walk-in

Chief Complaint

History of Present Illness

[Document the details surrounding the child’s chief complaint. Include onset, duration, frequency, severity, progression and any associated symptoms. Describe symptoms and events chronologically. Include all positive symptoms. Describe the parent’s account of the current issues they are having in relation to the chief complaint and any concerns or expectations they express. Include all positive symptom. Sort the bullet points in the HPI section based on chronological order and combine events on same day into single bullet. Omit year of dates Include pertinent negative symptoms at the end of the section. Include details about oral intake, such as breastfeeding or formula feeding, introduction of solid foods, current diet. Use bullet form with symbol "-". DO NOT use subjects like "The patient". DO NOT use pronouns. Do not lump together. Sort bullet points chronologically.] For example: - [Time, eg date or 2 days ago]: [Symptom description and any medical visits or treatments] - [Time, eg date or 2 days ago]: [Symptom description and any medical visits or treatments] ...

Past Medical History

[Summarize the patient's past medical history, including pregnancy and birth, any recent illnesses, treatments, ongoing medical conditions, previous hospitalizations, surgeries, medications, allergies, and immunization status.] (Use bullet form with symbol "-". Do not lump together.) For example: - Ongoing medical conditions: [Condition 1], [Condition 2]. - Recent [Condition] treated with [Medication]. - Current Medications: [List/None]. - Pregnancy and birth: [Include details of birth, pregnancy, any notable historical health information. If no information is provided, remove this bullet.]. - Previous Hospitalization: [List/None, include details of allergic reaction if present. If no information is provided, remove this bullet.]. - Previous Surgery: [List/None, include details of allergic reaction if present. If no information is provided, remove this bullet.]. - Allergies: [List/None, include details of allergic reaction if present]. - Immunizations: [Immunization Status, use Up to date/Not up to date, include details if discussed].

Family History

[Notable family history relevant to condition. Ensure all historical medical information is captured from the patient's history. If no information is provided, remove this section. Use bullet form with symbol "-". Do not lump together.]

Social History

[Provide details about the patient's living situation, family dynamics, and any relevant social factors. If no information is provided, remove this section. Use bullet form with symbol "-". Do not lump together.] For example: - Lives with [Family Members]. - [Pets/No pets] at home. - [List environmental risk factors, if mentioned].

Physical Examination

[Include detailed physical exam findings. Always include the following in physical examination. Can modify based on physical exam findings during encounter. Remove bullet symbol in Physical Examination.] GA: no distress, cooperative. HEENT: Mucus membrane moist. Normal TM x 2. Normal throat. No neck stiffness. No cervical lymphadenopathy. RESP: No indrawing, good bilateral air entry, lungs clear. CVS: S1 S2 normal, no murmur, well perfused. ABD: soft, non-tender, no guarding, no HSM, not distended, BS +. GU: Normal genitalia. Skin: No rash. No pallor. No jaundice. MSK: No swelling or redness. CNS: Cranial nerves 2-12 grossly intact. Normal power and tone. No focal neurological deficit.

Diagnosis

[List diagnoses made during the encounter. Diagnoses are listed in bullet form by numbers.] For example: 1. [Diagnosis 1] 2. [Diagnosis 2] 3. [Diagnosis 3]

Diagnosis

[List diagnoses made during the encounter. Diagnoses are listed in bullet form by numbers.] For example: 1. [Diagnosis 1] 2. [Diagnosis 2] 3. [Diagnosis 3]

Plan

[Outline the treatment plan, including medications, dosages, and instructions for use. Include any follow-up instructions or criteria for seeking further medical care. Ensure the plan outlines clear, actionable recommendations related to the assessment. Use bullet form with symbol "-". Do not lump together.] - [Management recommendations, in the following order: further investigations, medications, non-pharmacological management, and follow-up plan] - [Always keep this bullet. Can add more information if discussed during encounter.] Seek acute care if recurrent/persistent fever > 48 hours, difficulty breathing, vomiting, poor drinking, no urine > 6-8 hours, lethargy, or new concern.

Plan

[Outline the treatment plan, including medications, dosages, and instructions for use. Include any follow-up instructions or criteria for seeking further medical care. Ensure the plan outlines clear, actionable recommendations related to the assessment. Use bullet form with symbol "-". Do not lump together.] - [Management recommendations, in the following order: further investigations, medications, non-pharmacological management, and follow-up plan] - [Always keep this bullet. Can add more information if discussed during encounter.] Seek acute care if recurrent/persistent fever > 48 hours, difficulty breathing, vomiting, poor drinking, no urine > 6-8 hours, lethargy, or new concern.