Pediatric sick visit
Pediatrics

Blank documentation outlines. Adapt to the encounter and your practice requirements; complete only findings and care actually documented.

ENCOUNTER
Patient name: [ ]
Date of birth: [ ]
Date and time of encounter: [ ]
Clinician: [ ]

HISTORY
Parent, caregiver or patient present: [ ]
Chief concern, onset and symptom course: [ ]
Associated symptoms actually asked about and responses: [ ]
Intake, output and activity as reported: [ ]
Sick contacts, exposures and treatment already tried: [ ]
Immunization status as reviewed: [ ]
Medications and allergies: [ ]

EVALUATION
Weight and vitals measured, with units: [ ]
Hydration assessment findings: [ ]
Focused examination findings: [ ]
Testing obtained and results: [ ]

ASSESSMENT AND MANAGEMENT
Working diagnosis and differential: [ ]
Treatment provided or prescribed, with weight-based dose if applicable: [ ]
Disposition and rationale: [ ]
Return precautions explained and to whom: [ ]

FOLLOW-UP
Follow-up timing and purpose: [ ]
Return precautions discussed: [ ]
Patient questions and understanding: [ ]