Charting pediatric comprehensive and symptom-focused health care visits

Charting pediatric comprehensive and symptom-focused health care visits

Karen G. Duderstadt

Charting the health care visit

Comprehensive assessment of the infant, child, and adolescent and accurate charting in the health record are the hallmarks of quality professional practice for the pediatric health care provider. Documentation of the thorough physical examination in the health record is as important to the pediatric health visit as the comprehensive assessment, and it is the legal responsibility of every pediatric health care provider to accurately record all aspects of the health care visit. Included in this chapter are templates for the comprehensive well-child visit, the continuity well-child visit, the symptom-focused visit, and the preparticipation physical evaluation to assist the pediatric health care provider. A sample electronic health record (EHR) is also provided.

Comprehensive well-child visit

The initial comprehensive well-child visit is composed of subjective data, which includes all components of the health history, objective data from the physical examination including vital signs and laboratory screening, assessment and/or list of health conditions, anticipatory guidance for activities of daily living, a plan for each health condition, and follow-up with the child and family. Figure 20-1 presents a sample form for charting the comprehensive well-child visit. Figure 20-2 presents a form for a continuity well-child visit.

FIGURE 20-1 Comprehensive well-child visit—initial visit form.

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Tags: Pediatric Physical Examination An Illustrated Handbook

Jul 3, 2016 | Posted by admin in PEDIATRICS | Comments Off

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