brevaPediatric sick visit
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: [ ]