Well-child 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: [ ]
Concerns raised: [ ]
Interval history since last visit: [ ]
Feeding or nutrition, sleep, elimination and activity as reported: [ ]
School or childcare and behavior as reported: [ ]

GROWTH AND VITALS
Weight, length or height and head circumference if measured, with units and percentiles: [ ]
Body mass index percentile if calculated: [ ]
Other vitals measured, with units: [ ]

DEVELOPMENT AND SCREENING
Developmental or behavioral screening tool and result: [ ]
Other screening performed and results: [ ]
Vision and hearing screening and results if performed: [ ]

EXAMINATION
Examination performed and findings: [ ]

IMMUNIZATIONS
Immunization record reviewed: [ ]
Vaccines given today, with product, lot, site and route: [ ]
Vaccines deferred or declined and reason: [ ]

ASSESSMENT AND PLAN
Problems addressed today: [ ]
Anticipatory guidance discussed: [ ]
Referrals and orders: [ ]

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