newborn well visit soap note

Well Child Check Visit Notes

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Well-Child Visits: Parent and Patient Education

The Bright Futures Parent and Patient Educational Handouts help guide anticipatory guidance and reinforce key messages (organized around the 5 priorities in each visit) for the family. Each educational handout is written in plain language to ensure the information is clear, concise, relevant, and easy to understand. Each educational handout is available in English and Spanish (in HTML and PDF format). Beginning at the 7 year visit , there is both a Parent and Patient education handout (in English and Spanish).

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Home > Blog > Pediatric SOAP Notes (With Examples and Template)

Pediatric SOAP Notes (With Examples and Template)

Courtney Gardner, MSW

Hate writing progress notes? Join thousands of happy therapists using Mentalyc AI.

You won't believe the transformation your SOAP notes will undergo when you start working with kids! It's time to take your pediatric SOAP notes to the next level. Get ready to learn how to make your notes to fit the needs of your little clients, including what to include, examples, templates, and expert tips. We'll also explore pediatric documentation's unique benefits and challenges and why it demands a specialized approach. Let's explore pediatric documentation's distinct benefits and challenges so you can improve your notes for little ones, regardless of your experience level.

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What Are SOAP Notes and Why Use Them for Pediatric Clients?

When working with children, it's essential to use SOAP notes.  SOAP notes are a type of progress note used by mental health providers to document patient encounters. SOAP notes are valuable for tracking a child's progress , communicating with other providers, and justifying medical necessity for insurance purposes.

The acronym stands for:

• S ubjective - The client's chief complaint and history in their own words
• O bjective - Your observations and measurements
• A ssessment - Your analysis and impressions
• P lan - Your plan for treatment, follow-up, and goals

For pediatric clients, SOAP notes offer a structured and consistent way to document developmental milestones, behavioral changes, responses to treatment, and more. This comprehensive record can help monitor growth and skills and assess the effectiveness of interventions .

Adapting SOAP Notes for Pediatric Behavioral Health

When documenting pediatric behavioral health care, it's essential to adapt SOAP notes to the unique needs of young patients. This involves asking creative questions to understand their thoughts and feelings,  observing behaviors and emotions, and considering developmental stages and family dynamics in assessments. Plans may also involve parental involvement or community resources.

Pediatric SOAP notes require modifications to accommodate the needs of child patients and their families. Here are the key adaptations:

• Shorter, more straightforward sentences and words.  Sentence length should aim for 8-12 words to match a child's attention span. Avoid complex medical terminology.
• More spacing and bullet points.  Extra spacing between each section and bullet points within sections make the notes easier for children and caregivers to follow.
• Pictures and drawings . Illustrations and simple diagrams can supplement written notes, especially for younger patients.
• Focus on function, not just symptoms . Note how the child's condition impacts their ability to function at school and home.
• Provide take-home summaries.  Give families a brief overview of diagnoses, recommendations, and follow-up to assist with home care.

Automatically Generate HIPAA Compliant SOAP Notes

These adaptations help create functional, informative, and family-centered pediatric SOAP notes. They communicate your recommendations so that children and caregivers can easily understand and use them to improve the patient's health and well-being.

When writing your pediatric SOAP notes, remember:

• Children are still developing and have different needs than adults, which should be reflected in your documentation.
• Children's behaviors and symptoms may have different root causes than in adults, requiring different interventions and strategies. This should be evident in the documentation.
• Pediatric patients have caregivers involved in their treatment, so documentation must also consider the family's needs.

The Benefits and Challenges of Pediatric SOAP Notes

The advantages of using pediatric SOAP notes are extensive. They help improve the quality of care by promoting a systematic and thoughtful approach. They also aid in better communication among healthcare providers. Detailed notes can also be crucial in addressing concerns about a child's safety or progress. Moreover, pediatric SOAP notes enable early intervention, particularly important for children with developmental delays or learning differences. By promptly identifying issues and needs, healthcare professionals can collaborate with parents to provide the necessary support for children at a young age, leading to better outcomes.

However, documenting for pediatric clients does present some challenges. These include the need to keep notes concise yet comprehensive and to maintain client confidentiality. Concentrating on behaviors and conversations rather than personal interpretations and  using the child's words  and objective observations is vital.

Children typically have shorter attention spans, and communicating with nonverbal or minimally verbal children requires creativity. In such cases, it's essential to interpret behaviors and cues rather than relying on self-report. Building rapport with children also takes time, affecting the frequency of follow-up visits. Despite these challenges, the benefits of creating thorough, personalized pediatric SOAP notes far outweigh any difficulties.

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Best practices for writing pediatric soap notes.

Adhering to these best practices will make your pediatric SOAP notes a more effective tool for assessment and treatment.

Emphasize Behavior and Development

Carefully observe the child's behavior, moods, social abilities, interests, personality, and development. Note any delays or difficulties and track their progress. Give specific examples of the child's social interactions and skills compared to typical development at that age. This information will help inform future treatment plans.

Include Information from Caregivers and Teachers

When documenting a child's progress , ask open-ended questions to obtain perspectives from the child's parents, guardians, teachers, and other caregivers. Inquire about their observations of the child's symptoms, progress, challenges, strengths, environment, support systems, and needs. Also, ask them to voice any specific concerns. Note their insights in your SOAP notes to understand the child's functioning comprehensively. This context will help you provide appropriate treatment.

Discuss Treatment Approach and Response

Describe your therapeutic approach with the child, including how you use play, workbooks, and conversations to engage them. Discuss the child's responses and progress in treatment, noting any difficulties or resistance encountered and how your methods help them develop skills and overcome challenges.

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Focus on strengths.

Rather than focusing solely on a child's problems and symptoms, which can dishearten families, note their strengths, talents, interests, and sources of joy. Identify protective factors in their lives, such as supportive friends, activities they excel in, and caring adults. Building on these strengths provides growth opportunities.

Recommend Practical Strategies

To empower and encourage families, offer practical advice on helping children, such as allowing extra response time, establishing routines, presenting choices, and rewarding good behavior. Specific, actionable strategies make families feel more capable and hopeful.

Provide a Safe Space

Take a compassionate, understanding approach so the child and family feel your office is a secure environment where they are listened to, valued, and cared for. Foster trust by showing empathy, encouraging, and focusing on their strengths. This will make children and caregivers more open to sharing freely and engaging actively in therapy.

Set Achievable Goals .

When setting goals for a child, aim for ones that are realistic yet challenging for their age, and break down any larger goals into smaller, measurable steps.

Review notes Regularly.

Review your notes periodically to monitor progress and watch for warning signs, ensuring your documentation remains up-to-date and effective.

Template for Pediatric SOAP Notes

The following template covers the core areas to address for each section of the SOAP note while allowing flexibility for each pediatric patient's unique needs, developmental level, and concerns. Using this framework can help ensure consistent and complete documentation of mental health concerns in children and adolescents.

SOAP notes for pediatric patients with mental and behavioral health concerns will include the following sections:

Subjective (S)

• A chief complaint or reason for visit, reported by the child or caregiver
• Pertinent developmental, medical, family, and social histories
• Symptoms and concerns, using child's words when possible

Objective (O)

Provide factual observations of the client's:

• Appearance and behavior
• Speech and language skills
• Mood and affect
• Thought processes
• Perception, cognition, and memory
• Relevant physical exam findings

Assessment (A)

• DSM (or ICD) diagnoses in order of importance
• Any relevant differential diagnoses
• Medication changes
• Therapy or behavioral recommendations tailored to the child's age and needs
• Safety planning as needed
• Follow-up instructions and timing

Examples of Pediatric SOAP Notes for Common Clinical Situations

These examples show how a clinician would document common issues in children and teens: generalized anxiety, separation anxiety, depression, and ADHD. Following the standard SOAP format, the notes use age-appropriate language, suggest initial evaluations and referrals, and outline the next steps. Keeping detailed records of your work with young clients enables the best care and continuity if other providers are involved.

Generalized Anxiety  in an 8-year-old

S : B.T. reports feeling "worried all the time" and having trouble sleeping. His mother says he seems anxious and has frequent stomachaches.

O : B.T. presented as tense but cooperative. He reported worries about school, friends, and family health. His speech was rapid, and eye contact was fleeting. Billy said his stomach "hurts a lot."

A : Generalized Anxiety Disorder, Adjustment Disorder with Anxiety

P : Recommended coping strategies like deep breathing, limiting screen time before bed, and journaling worries. Referred to a child psychologist for assessment and potential therapy. Follow-up in two weeks.

Separation Anxiety in a 7-year-old

S : L.Q. is a 7-year-old girl who has had difficulty separating from her parents, especially her mother, in the past few months. Her mother reports that L.Q cries and clings whenever she tries to leave for school or other activities.

O : L.Q was shy but cooperative during the interview. She became tearful when discussing being separated from her mother and reported frequent worries that something bad would happen if her mother were not with her.

A : Separation Anxiety Disorder

P : Recommended gradual exposure exercises for L.Q and her mother to practice separating for short periods. Referred L.Q to a child psychologist for cognitive behavioral therapy to address her anxiety. Provided a handout on separation anxiety for parents. Follow-up in four weeks to monitor progress and adherence to treatment plan .

Depression  in a 15-year-old

S : M.C.'s parents have brought him in due to changes in behavior and mood over the past three months. They report that M.C. has lost interest in activities, sleeps excessively, and gained weight. His grades have declined significantly.

O : During the interview, M.C. appeared lethargic and discouraged. He reported a lack of motivation, sadness, hopelessness, and poor concentration. He has also withdrawn from friends and hobbies.

A : Major Depressive Disorder

P : Recommended monitoring of mood, sleep, and appetite. Referred M.C. to a psychiatrist for medication evaluation and a psychologist for cognitive behavioral therapy. Provided handout on depression management strategies for adolescents—follow-up in two weeks to discuss a treatment plan and monitor for suicidal thoughts .

ADHD  in a 12-year-old

S : J.P. was brought in by her parents due to problems focusing in school and at home. Teachers report that J.P. is distractible, impulsive, and struggles to finish tasks.

O : J.P. was talkative and energetic. She had trouble sitting still during the interview and was easily distracted by noises outside the office. She reported difficulty paying attention in class and frequent interruptions.

A : Predominantly Inattentive Presentation of ADHD.

P : Recommended parent/teacher-completed behavior rating scales. Referred to a psychiatrist to consider medication for symptoms and a counselor for behavioral strategies. Scheduled a follow-up in three to four weeks to review recommendations and next steps.

You now have an overview of pediatric SOAP notes and how to adapt them for children and teens. Preparing and approaching SOAP note writing with intentionality is essential to ensure a clear and comprehensive clinical picture. Mastering SOAP notes takes practice, but having SOAP notes templates and examples can assist clinicians in this process. When documenting pediatric behavioral health concerns, it is crucial to consider their unique considerations. Remember that perfecting SOAP notes may require practice, but the benefits for children are worth the effort. Start with a basic template and then personalize it to meet your requirements. Additionally, you can request to view examples from colleagues and seek feedback from a supervisor to refine your notes. With regular use, documenting pediatric SOAP notes will become second nature; we believe in you!

Sign up for Mentalyc today , a HIPPA-compliant AI notes software designed to assist you in generating your SOAP notes , increase efficiency, and automate your notes with additional templates so you can spend more time doing what you love—helping kids!

FAQs About Pediatric SOAP Notes for Mental and Behavioral Health

How detailed do pediatric soap notes need to be.

SOAP notes for children and teens should provide a high-level overview of the session rather than an exhaustive account of everything discussed. Focus on the key highlights, events, and takeaways. Be concise yet capture the essential details another clinician would need to get up to speed on the client's care. Provide enough context around discussions and the client's mental/emotional state, but avoid verbatim transcripts.

Should parents or guardians review and sign the SOAP notes?

Whether parents should review and sign a child's SOAP notes depends on the child's age, the clinician's discretion, and local laws. For young children who are not yet able to consent to treatment themselves, it is typically required for parents to review and sign the notes. However, for teenagers who are mature enough to consent to treatment confidentially, some clinicians may share general overviews of sessions and treatment progress with parents while keeping specific details private. Other clinicians may assess whether the teen can consent to treatment autonomously. Nevertheless, clinicians must always follow their state laws regarding confidentiality and informed consent for minors.

Should goals and treatment plans be designed for each child's age?

Yes, the treatment goals and plans in SOAP notes should always be designed specifically to the child's unique needs, issues, and stages of development. Goals and interventions appropriate for a teenager will differ significantly from those for a young child. An individualized approach is essential for effective pediatric behavioral health treatment.

At what age do children's SOAP notes no longer require parental consent?

The age at which parental consent is no longer required for children's mental health SOAP notes varies by state and clinician discretion. Generally, once a child reaches the age of maturity defined by law in their state (around age 14 to 17), parental consent may no longer be legally required. However, clinicians should consider the child's cognitive and emotional development to determine the capacity for autonomous consent.

Should I write SOAP notes for each problem or diagnosis?

The level of documentation required depends on the case's complexity and the client's needs. For clients with multiple diagnoses or issues, separate SOAP notes can be written for each problem or diagnosis. This approach ensures that each condition receives the necessary attention and documentation. However, a single comprehensive SOAP note may suffice for more straightforward cases with only one or two main issues. The important thing is to document all critical details to support the client's treatment.

How often should I update my pediatric client's SOAP notes?

Updating your client's SOAP notes after every session or critical interaction is best. This will ensure that the notes accurately reflect your client's mental health status, treatment progress, and changes over time. For ongoing clients, reviewing the previous SOAP notes before each session can also help guide the discussion and remind you of important details. Writing a new SOAP note after each session is ideal for clients you see weekly or bi-weekly.

What should I include in the subjective section for kids?

The subjective section of a pediatric SOAP note should include observations about the client's mood, behavior, sleep, and appetite. It's important to note any changes in functioning at home or school. Summarize any concerns the parents mention regarding their child. You can also include quotes from the client or their caregivers that provide insight into their mental state. The goal is to capture a holistic picture of how the client is doing from a subjective perspective.

All examples of mental health documentation are fictional and for informational purposes only.

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Template for Notes and Presentations

Clinical rotations for students.

Although the official medical record is now entirely electronic, students may choose to write admission and follow-up notes on lined progress note paper. Whether notes are done electronically or on paper, it is important that the information is recorded and verbally presented in a logical, coherent manner and that a succinct assessment and plan is provided. Our suggested format for both admit and progress notes is presented on this page.

2/9/08 08:15

MS Admission Note

ID: 12 hour old term newborn

HPI: Baby Boy Brown was born at 39+3 weeks by NSVD to a 27yo G3P1011 mom with prenatal labs O+, Ab screen -, HBsAg-, VDRL non-reactive, GC/CT - , HIV -, PPD+/CXR-. Pregnancy was complicated by PIH, treated with Mag. ROM was 7 hours prior to delivery with clear fluid. Delivery was complicated by tight nuchal cord, cut before delivery. Apgars 3 and 9. Baby received PPV for 30 seconds to improve color and tone.

Baby has been doing well since birth, breastfed x3, stool x 1 and void x 1, VSS. Mom states that feeding are going well, but she complains of sore nipples.

FH: sibling under bili lights for 2 days in newborn nursery, negative for congenital diseases, childhood deaths, or atopic diseases.

SH: intact family, 3 yo sib; has all baby needs including car seat. Plans to receive care at LPCH clinic.

PE: wt - 3578g, length - 49.5cm, OFC - 34cm, temp 36.7 - 37.1, HR 145 - 160, RR 48 - 52

gen - well appearing, NL tone/color/activity, crying with exam

skin - no jaundice, + red macules with central papules scattered on chest and legs

HEENT- normocephalic, + fluctuent area over R parietal bone, does not cross sutures, + RR B eyes, ears NL set/shape, palate intact, tongue WNL

neck - WNL, clavicles intact B

lungs - clear B, - G/F/R

CV - RRR without m, pulses +2 B

abd - soft, non-distended, liver palpable 2 cm below RCM, umbilical stump intact/clamped

genitalia - NL male with testes descended B, anus patent

ext - hips stable B, all WNL

neuro- NL suck, grasp, Moro reflexes, DTRs +2 B

A/P: Term AGA newborn with low first apgar, with erythema toxicum rash and R parietal cephalohematoma. Mom with soreness during feeds.

Expect spontaneous resolution of rash within 1 -2 weeks

Expect spontaneous resolution of cephalohematoma, but follow clinically for jaundice, TBili to be drawn at 24 hours of life with newborn screen.

Discussed with mom expectations for feedings, RN to help with latch technique and position, recommended BF class.

Susan Student, MS 3, pager 19790

CoSignature of MD

MS Progress Note

ID: Term AGA male, DOL #2

S: baby did well O/N, mom reports much less pain with feedings

O: VSS, BF x 11, void x 2, stool x 5 (mec), TB at 26 hours of life - 6.5, algo was passed B

PE: wt - 3408g (down 5% from BW)

gen - well appearing, NL tone/color/activity, awake and alert

skin - mild facial jaundice, + red macules with central papules scattered on chest, abd, and legs

HEENT- normocephalic, + fluctuent area over R parietal bone unchanged from yest, + RR B eyes, ears NL set/shape, palate intact, tongue WNL

abd - soft, non-distended, liver palpable 2 cm below RCM, umbilical stump intact/dried

A/P: Term AGA male, DOL #2, now feeding better, with mild jaundice/cephalohematoma and TBili low int. risk on Bhutani graph.

Follow jaundice clinically, consider repeat TB in am if exam worsening.

Routine care.

• Daily Schedule
• Roles and Responsibilities
• Newborn Exam
• Notes and Presentations

2-Week-Old Well Child Visit

Congratulations on the birth of your baby.

Life with your two-week-old revolves around feeding, sleeping, and crying. Your newborn infant should tightly grasp with his or her hands and respond to light, noise and movement.

Amounts - Babies need approximately 50 calories per pound of body weight each day. Both breast milk and formula contain 20 calories per ounce and all the nutrients required. Therefore, your baby should consume approximately two to two and one half ounces per pound of body weight in each 24-hour period. There is no need to supplement with other food or excess water. Call our office if your child seems to lack interest in breast or bottle feeding, or if your baby's appetite suddenly decreases.

Preparation - Prepare commercial formula by the manufacturer's directions. If you are concerned about the safety of your water, you can boil it for no more than one minute and allow to cool. Boiling the water only kills the germs, so if using well water it is also important to test for nitrates before giving it to infants younger than 12 months. It is not necessary to sterilize bottles; washing in hot, soapy water or the dishwasher is adequate.

Frequency - As a general rule, babies should be fed on demand. Full-term infants require feeding approximately every two to four hours, both day and night. Some breastfed babies may want to nurse slightly more frequently. Please see the breast feeding links for more information. 

The American Academy of Pediatrics recommends supplementing exclusively breastfed babies and those who are formula fed with Vitamin D 400 IU once a day. One such supplement, D-vi-Sol, can be purchased over the counter. Check the package of the product you buy for dosing instructions.

Development

At this age your baby should:

• Readily locate the nipple for feeding
• Have a strong sucking reflex
• Respond to light, noise and movement
• Tightly grasp with his hands

Vaccinations

There are no vaccinations given to your child at today's visit, unless your infant did not receive the hepatitis B vaccine at birth.

Common Issues And Concerns

Medications.

At this age you should not give your infant any type of medication without advice from your physician

• The AAP recommends that all newborns be placed on their back to sleep  in their own crib or bassinet. Use a firm mattress. No pillows, heavy blankets (only thin swaddle), or stuffed animals should be in the crib. Don't use positioners or bumpers.
• Hold and cuddle your baby if crying; gentle motion seems to induce comfort and sleep. You can't spoil them at this age.
• Do not feed your baby if he cries and less than two hours have passed since the previous feeding. Babies who feed frequently during the day become hungry at frequent intervals during the night.
• Make middle-of-the-night feedings brief and boring. Don't turn on the lights, talk to, or rock your baby. Feed him quickly and quietly.

At this age a fever may be a warning sign of a serious infection. A temperature over 100.4 degrees taken rectally is a fever. Contact your physician IMMEDIATELY if this occurs. Do not give Tylenol or any other medication before your child is evaluated by a physician.

Babies have sensitive skin and frequently develop transient rashes.

Hiccups, Sneezing, Spitting-up and Passing Gas

These are all normal occurrences in the newborn period.

Bowel movements are highly variable in frequency, amount, color and consistency. Each baby is different.

Crying is normal for newborn babies and may occur for many different reasons.  Remember, it is not usually something you are doing wrong, so DON'T BLAME YOURSELF.

Eye Drainage

Blocked tear ducts are a common occurrence and may cause a thin watery eye discharge. If the whites of the eye appear red, contact your physician.

Your child needs to be in a Department of Transportation approved car seat that is rear facing until two years of age. Use the car seat in the back seat of the car and make sure the seat is securely belted into the car. Use built in seat anchors if available in your car.

Depression During and After Pregnancy

Depression during and after pregnancy is common and treatable. Having a baby is challenging and every woman deserves support. We will screen for caregiver depression at your child's well-child visits through the first year. Talk to your child's healthcare provider or your healthcare provider if you are experiencing symptoms. Please review this information from the CDC regarding postpartum depression. There are also resources available. Contact the Postpartum Support International Warmline and a trained helpline volunteer will call/text you back to identify a local coordinator and resources in your area:

• Call 1-800-944-4773, #1 en Espanol or #2 English
• Text 503-894-9453

Next Well Child Visit

Your child's next well child visit should be when he/she is two months of age.

Two convenient locations

1000 W. Broadway Suite 100 Oviedo, FL 32765 ( directions )

P: 407-767-2477

F: 407-767-1627

846 Lake Howell Rd. Maitland, FL 32751 ( directions )

Website maintenance is scheduled for Saturday, September 7, and Sunday, September 8. Short disruptions may occur during these days.

KATHERINE TURNER, MD

Am Fam Physician. 2018;98(6):347-353

Related letter: Well-Child Visits Provide Physicians Opportunity to Deliver Interconception Care to Mothers

Author disclosure: No relevant financial affiliations.

The well-child visit allows for comprehensive assessment of a child and the opportunity for further evaluation if abnormalities are detected. A complete history during the well-child visit includes information about birth history; prior screenings; diet; sleep; dental care; and medical, surgical, family, and social histories. A head-to-toe examination should be performed, including a review of growth. Immunizations should be reviewed and updated as appropriate. Screening for postpartum depression in mothers of infants up to six months of age is recommended. Based on expert opinion, the American Academy of Pediatrics recommends developmental surveillance at each visit, with formal developmental screening at nine, 18, and 30 months and autism-specific screening at 18 and 24 months; the U.S. Preventive Services Task Force found insufficient evidence to make a recommendation. Well-child visits provide the opportunity to answer parents' or caregivers' questions and to provide age-appropriate guidance. Car seats should remain rear facing until two years of age or until the height or weight limit for the seat is reached. Fluoride use, limiting or avoiding juice, and weaning to a cup by 12 months of age may improve dental health. A one-time vision screening between three and five years of age is recommended by the U.S. Preventive Services Task Force to detect amblyopia. The American Academy of Pediatrics guideline based on expert opinion recommends that screen time be avoided, with the exception of video chatting, in children younger than 18 months and limited to one hour per day for children two to five years of age. Cessation of breastfeeding before six months and transition to solid foods before six months are associated with childhood obesity. Juice and sugar-sweetened beverages should be avoided before one year of age and provided only in limited quantities for children older than one year.

Well-child visits for infants and young children (up to five years) provide opportunities for physicians to screen for medical problems (including psychosocial concerns), to provide anticipatory guidance, and to promote good health. The visits also allow the family physician to establish a relationship with the parents or caregivers. This article reviews the U.S. Preventive Services Task Force (USPSTF) and the American Academy of Pediatrics (AAP) guidelines for screenings and recommendations for infants and young children. Family physicians should prioritize interventions with the strongest evidence for patient-oriented outcomes, such as immunizations, postpartum depression screening, and vision screening.

Clinical Examination

The history should include a brief review of birth history; prematurity can be associated with complex medical conditions. 1 Evaluate breastfed infants for any feeding problems, 2 and assess formula-fed infants for type and quantity of iron-fortified formula being given. 3 For children eating solid foods, feeding history should include everything the child eats and drinks. Sleep, urination, defecation, nutrition, dental care, and child safety should be reviewed. Medical, surgical, family, and social histories should be reviewed and updated. For newborns, review the results of all newborn screening tests ( Table 1 4 – 7 ) and schedule follow-up visits as necessary. 2

PHYSICAL EXAMINATION

A comprehensive head-to-toe examination should be completed at each well-child visit. Interval growth should be reviewed by using appropriate age, sex, and gestational age growth charts for height, weight, head circumference, and body mass index if 24 months or older. The Centers for Disease Control and Prevention (CDC)-recommended growth charts are available. Percentiles and observations of changes along the chart's curve should be assessed at every visit. Include assessment of parent/caregiver-child interactions and potential signs of abuse such as bruises on uncommonly injured areas, burns, human bite marks, bruises on nonmobile infants, or multiple injuries at different healing stages. 8

The USPSTF and AAP screening recommendations are outlined in Table 2 . 3 , 9 – 27 A summary of AAP recommendations  is available. The American Academy of Family Physicians (AAFP) generally adheres to USPSTF recommendations. 28

MATERNAL DEPRESSION

Prevalence of postpartum depression is around 12%, 22 and its presence can impair infant development. The USPSTF and AAP recommend using the Edinburgh Postnatal Depression Scale or the Patient Health Questionnaire-2 to screen for maternal depression. The USPSTF does not specify a screening schedule; however, based on expert opinion, the AAP recommends screening mothers at the one-, two-, four-, and six-month well-child visits, with further evaluation for positive results. 23 There are no recommendations to screen other caregivers if the mother is not present at the well-child visit.

PSYCHOSOCIAL

With nearly one-half of children in the United States living at or near the poverty level, assessing home safety, food security, and access to safe drinking water can improve awareness of psychosocial problems, with referrals to appropriate agencies for those with positive results. 29 The prevalence of mental health disorders (i.e., primarily anxiety, depression, behavioral disorders, attention-deficit/hyperactivity disorder) in preschool-aged children is around 6%. 30 Risk factors for these disorders include having a lower socioeconomic status, being a member of an ethnic minority, and having a non–English-speaking parent or primary caregiver. 25 The USPSTF found insufficient evidence regarding screening for depression in children up to 11 years of age. 24 Based on expert opinion, the AAP recommends that physicians consider screening, although screening in young children has not been validated or standardized. 25

DEVELOPMENT AND SURVEILLANCE

Based on expert opinion, the AAP recommends early identification of developmental delays 14 and autism 10 ; however, the USPSTF found insufficient evidence to recommend formal developmental screening 13 or autism-specific screening 9 if the parents/caregivers or physician have no concerns. If physicians choose to screen, developmental surveillance of language, communication, gross and fine movements, social/emotional development, and cognitive/problem-solving skills should occur at each visit by eliciting parental or caregiver concerns, obtaining interval developmental history, and observing the child. Any area of concern should be evaluated with a formal developmental screening tool, such as Ages and Stages Questionnaire, Parents' Evaluation of Developmental Status, Parents' Evaluation of Developmental Status-Developmental Milestones, or Survey of Well-Being of Young Children. These tools are available. If results are abnormal, consider intervention or referral to early intervention services. The AAP recommends completing the previously mentioned formal screening tools at nine-, 18-, and 30-month well-child visits. 14

The AAP also recommends autism-specific screening at 18 and 24 months. 10 The USPSTF recommends using the two-step Modified Checklist for Autism in Toddlers (M-CHAT) screening tool  if a physician chooses to screen a patient for autism. 10 The M-CHAT can be incorporated into the electronic medical record, with the possibility of the parent or caregiver completing the questionnaire through the patient portal before the office visit.

IRON DEFICIENCY

Multiple reports have associated iron deficiency with impaired neurodevelopment. Therefore, it is essential to ensure adequate iron intake. Based on expert opinion, the AAP recommends supplements for preterm infants beginning at one month of age and exclusively breastfed term infants at six months of age. 3 The USPSTF found insufficient evidence to recommend screening for iron deficiency in infants. 19 Based on expert opinion, the AAP recommends measuring a child's hemoglobin level at 12 months of age. 3

Lead poisoning and elevated lead blood levels are prevalent in young children. The AAP and CDC recommend a targeted screening approach. The AAP recommends screening for serum lead levels between six months and six years in high-risk children; high-risk children are identified by location-specific risk recommendations, enrollment in Medicaid, being foreign born, or personal screening. 21 The USPSTF does not recommend screening for lead poisoning in children at average risk who are asymptomatic. 20

The USPSTF recommends at least one vision screening to detect amblyopia between three and five years of age. Testing options include visual acuity, ocular alignment test, stereoacuity test, photoscreening, and autorefractors. The USPSTF found insufficient evidence to recommend screening before three years of age. 26 The AAP, American Academy of Ophthalmology, and the American Academy of Pediatric Ophthalmology and Strabismus recommend the use of an instrument-based screening (photoscreening or autorefractors) between 12 months and three years of age and annual visual acuity screening beginning at four years of age. 31

IMMUNIZATIONS

The AAFP recommends that all children be immunized. 32 Recommended vaccination schedules, endorsed by the AAP, the AAFP, and the Advisory Committee on Immunization Practices, are found at https://www.cdc.gov/vaccines/schedules/hcp/child-adolescent.html . Immunizations are usually administered at the two-, four-, six-, 12-, and 15- to 18-month well-child visits; the four- to six-year well-child visit; and annually during influenza season. Additional vaccinations may be necessary based on medical history. 33 Immunization history should be reviewed at each wellness visit.

Anticipatory Guidance

Injuries remain the leading cause of death among children, 34 and the AAP has made several recommendations to decrease the risk of injuries. 35 – 42 Appropriate use of child restraints minimizes morbidity and mortality associated with motor vehicle collisions. Infants need a rear-facing car safety seat until two years of age or until they reach the height or weight limit for the specific car seat. Children should then switch to a forward-facing car seat for as long as the seat allows, usually 65 to 80 lb (30 to 36 kg). 35 Children should never be unsupervised around cars, driveways, and streets. Young children should wear bicycle helmets while riding tricycles or bicycles. 37

Having functioning smoke detectors and an escape plan decreases the risk of fire- and smoke-related deaths. 36 Water heaters should be set to a maximum of 120°F (49°C) to prevent scald burns. 37 Infants and young children should be watched closely around any body of water, including water in bathtubs and toilets, to prevent drowning. Swimming pools and spas should be completely fenced with a self-closing, self-latching gate. 38

Infants should not be left alone on any high surface, and stairs should be secured by gates. 43 Infant walkers should be discouraged because they provide no benefit and they increase falls down stairs, even if stair gates are installed. 39 Window locks, screens, or limited-opening windows decrease injury and death from falling. 40 Parents or caregivers should also anchor furniture to a wall to prevent heavy pieces from toppling over. Firearms should be kept unloaded and locked. 41

Young children should be closely supervised at all times. Small objects are a choking hazard, especially for children younger than three years. Latex balloons, round objects, and food can cause life-threatening airway obstruction. 42 Long strings and cords can strangle children. 37

DENTAL CARE

Infants should never have a bottle in bed, and babies should be weaned to a cup by 12 months of age. 44 Juices should be avoided in infants younger than 12 months. 45 Fluoride use inhibits tooth demineralization and bacterial enzymes and also enhances remineralization. 11 The AAP and USPSTF recommend fluoride supplementation and the application of fluoride varnish for teeth if the water supply is insufficient. 11 , 12 Begin brushing teeth at tooth eruption with parents or caregivers supervising brushing until mastery. Children should visit a dentist regularly, and an assessment of dental health should occur at well-child visits. 44

SCREEN TIME

Hands-on exploration of their environment is essential to development in children younger than two years. Video chatting is acceptable for children younger than 18 months; otherwise digital media should be avoided. Parents and caregivers may use educational programs and applications with children 18 to 24 months of age. If screen time is used for children two to five years of age, the AAP recommends a maximum of one hour per day that occurs at least one hour before bedtime. Longer usage can cause sleep problems and increases the risk of obesity and social-emotional delays. 46

To decrease the risk of sudden infant death syndrome (SIDS), the AAP recommends that infants sleep on their backs on a firm mattress for the first year of life with no blankets or other soft objects in the crib. 45 Breastfeeding, pacifier use, and room sharing without bed sharing protect against SIDS; infant exposure to tobacco, alcohol, drugs, and sleeping in bed with parents or caregivers increases the risk of SIDS. 47

DIET AND ACTIVITY

The USPSTF, AAFP, and AAP all recommend breastfeeding until at least six months of age and ideally for the first 12 months. 48 Vitamin D 400 IU supplementation for the first year of life in exclusively breastfed infants is recommended to prevent vitamin D deficiency and rickets. 49 Based on expert opinion, the AAP recommends the introduction of certain foods at specific ages. Early transition to solid foods before six months is associated with higher consumption of fatty and sugary foods 50 and an increased risk of atopic disease. 51 Delayed transition to cow's milk until 12 months of age decreases the incidence of iron deficiency. 52 Introduction of highly allergenic foods, such as peanut-based foods and eggs, before one year decreases the likelihood that a child will develop food allergies. 53

With approximately 17% of children being obese, many strategies for obesity prevention have been proposed. 54 The USPSTF does not have a recommendation for screening or interventions to prevent obesity in children younger than six years. 54 The AAP has made several recommendations based on expert opinion to prevent obesity. Cessation of breastfeeding before six months and introduction of solid foods before six months are associated with childhood obesity and are not recommended. 55 Drinking juice should be avoided before one year of age, and, if given to older children, only 100% fruit juice should be provided in limited quantities: 4 ounces per day from one to three years of age and 4 to 6 ounces per day from four to six years of age. Intake of other sugar-sweetened beverages should be discouraged to help prevent obesity. 45 The AAFP and AAP recommend that children participate in at least 60 minutes of active free play per day. 55 , 56

Data Sources: Literature search was performed using the USPSTF published recommendations and the AAP Periodicity table . PubMed searches were completed using the key terms pediatric, obesity prevention, and allergy prevention with search limits of infant younger than 23 months or pediatric younger than 18 years. The searches included systematic reviews, randomized controlled trials, clinical trials, and position statements. Essential Evidence Plus was also reviewed. Search dates: May through October 2017.

Gauer RL, Burket J, Horowitz E. Common questions about outpatient care of premature infants. Am Fam Physician. 2014;90(4):244-251.

American Academy of Pediatrics; Committee on Fetus and Newborn. Hospital stay for healthy term newborns. Pediatrics. 2010;125(2):405-409.

Baker RD, Greer FR Committee on Nutrition, American Academy of Pediatrics. Diagnosis and prevention of iron deficiency and iron-deficiency anemia in infants and young children (0–3 years of age). Pediatrics. 2010;126(5):1040-1050.

Mahle WT, Martin GR, Beekman RH, Morrow WR Section on Cardiology and Cardiac Surgery Executive Committee. Endorsement of Health and Human Services recommendation for pulse oximetry screening for critical congenital heart disease. Pediatrics. 2012;129(1):190-192.

American Academy of Pediatrics Newborn Screening Authoring Committee. Newborn screening expands: recommendations for pediatricians and medical homes—implications for the system. Pediatrics. 2008;121(1):192-217.

American Academy of Pediatrics, Joint Committee on Infant Hearing. Year 2007 position statement: principles and guidelines for early hearing detection and intervention programs. Pediatrics. 2007;120(4):898-921.

Maisels MJ, Bhutani VK, Bogen D, Newman TB, Stark AR, Watchko JF. Hyperbilirubinemia in the newborn infant > or = 35 weeks' gestation: an update with clarifications. Pediatrics. 2009;124(4):1193-1198.

Christian CW Committee on Child Abuse and Neglect, American Academy of Pediatrics. The evaluation of suspected child physical abuse [published correction appears in Pediatrics . 2015;136(3):583]. Pediatrics. 2015;135(5):e1337-e1354.

Siu AL, Bibbins-Domingo K, Grossman DC, et al. Screening for autism spectrum disorder in young children: U.S. Preventive Services Task Force recommendation statement. JAMA. 2016;315(7):691-696.

Johnson CP, Myers SM American Academy of Pediatrics Council on Children with Disabilities. Identification and evaluation of children with autism spectrum disorders. Pediatrics. 2007;120(5):1183-1215.

Moyer VA. Prevention of dental caries in children from birth through age 5 years: U.S. Preventive Services Task Force recommendation statement. Pediatrics. 2014;133(6):1102-1111.

Clark MB, Slayton RL American Academy of Pediatrics Section on Oral Health. Fluoride use in caries prevention in the primary care setting. Pediatrics. 2014;134(3):626-633.

Siu AL. Screening for speech and language delay and disorders in children aged 5 years and younger: U.S. Preventive Services Task Force recommendation statement. Pediatrics. 2015;136(2):e474-e481.

Council on Children with Disabilities, Section on Developmental Behavioral Pediatrics, Bright Futures Steering Committee, Medical Home Initiatives for Children with Special Needs Project Advisory Committee. Identifying infants and young children with developmental disorders in the medical home: an algorithm for developmental surveillance and screening [published correction appears in Pediatrics . 2006;118(4):1808–1809]. Pediatrics. 2006;118(1):405-420.

Bibbins-Domingo K, Grossman DC, Curry SJ, et al. Screening for lipid disorders in children and adolescents: U.S. Preventive Services Task Force recommendation statement. JAMA. 2016;316(6):625-633.

National Heart, Lung, and Blood Institute. Expert panel on integrated guidelines for cardiovascular health and risk reduction in children and adolescents. October 2012. https://www.nhlbi.nih.gov/sites/default/files/media/docs/peds_guidelines_full.pdf . Accessed May 9, 2018.

Moyer VA. Screening for primary hypertension in children and adolescents: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med. 2013;159(9):613-619.

Flynn JT, Kaelber DC, Baker-Smith CM, et al. Clinical practice guideline for screening and management of high blood pressure in children and adolescents [published correction appears in Pediatrics . 2017;140(6):e20173035]. Pediatrics. 2017;140(3):e20171904.

Siu AL. Screening for iron deficiency anemia in young children: USPSTF recommendation statement. Pediatrics. 2015;136(4):746-752.

U.S. Preventive Services Task Force. Screening for elevated blood lead levels in children and pregnant women. Pediatrics. 2006;118(6):2514-2518.

Screening Young Children for Lead Poisoning: Guidance for State and Local Public Health Officials . Atlanta, Ga.: U.S. Public Health Service; Centers for Disease Control and Prevention; National Center for Environmental Health; 1997.

O'Connor E, Rossom RC, Henninger M, Groom HC, Burda BU. Primary care screening for and treatment of depression in pregnant and post-partum women: evidence report and systematic review for the U.S. Preventive Services Task Force. JAMA. 2016;315(4):388-406.

Earls MF Committee on Psychosocial Aspects of Child and Family Health, American Academy of Pediatrics. Incorporating recognition and management of perinatal and postpartum depression into pediatric practice. Pediatrics. 2010;126(5):1032-1039.

Siu AL. Screening for depression in children and adolescents: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med. 2016;164(5):360-366.

Weitzman C, Wegner L American Academy of Pediatrics Section on Developmental and Behavioral Pediatrics; Committee on Psychosocial Aspects of Child and Family Health; Council on Early Childhood; Society for Developmental and Behavioral Pediatrics; American Academy of Pediatrics. Promoting optimal development: screening for behavioral and emotional problems [published correction appears in Pediatrics . 2015;135(5):946]. Pediatrics. 2015;135(2):384-395.

Grossman DC, Curry SJ, Owens DK, et al. Vision screening in children aged 6 months to 5 years: U.S. Preventive Services Task Force recommendation statement. JAMA. 2017;318(9):836-844.

Donahue SP, Nixon CN Committee on Practice and Ambulatory Medicine, Section on Ophthalmology, American Academy of Pediatrics; American Association of Certified Orthoptists, American Association for Pediatric Ophthalmology and Strabismus, American Academy of Ophthalmology. Visual system assessment in infants, children, and young adults by pediatricians. Pediatrics. 2016;137(1):28-30.

Lin KW. What to do at well-child visits: the AAFP's perspective. Am Fam Physician. 2015;91(6):362-364.

American Academy of Pediatrics Council on Community Pediatrics. Poverty and child health in the United States. Pediatrics. 2016;137(4):e20160339.

Lavigne JV, Lebailly SA, Hopkins J, Gouze KR, Binns HJ. The prevalence of ADHD, ODD, depression, and anxiety in a community sample of 4-year-olds. J Clin Child Adolesc Psychol. 2009;38(3):315-328.

American Academy of Pediatrics Committee on Practice and Ambulatory Medicine, Section on Ophthalmology, American Association of Certified Orthoptists, American Association for Pediatric Ophthalmology and Strabismus, American Academy of Ophthalmology. Visual system assessment of infants, children, and young adults by pediatricians. Pediatrics. 2016;137(1):28-30.

American Academy of Family Physicians. Clinical preventive service recommendation. Immunizations. http://www.aafp.org/patient-care/clinical-recommendations/all/immunizations.html . Accessed October 5, 2017.

Centers for Disease Control and Prevention. Recommended immunization schedule for children and adolescents aged 18 years or younger, United States, 2018. https://www.cdc.gov/vaccines/schedules/hcp/child-adolescent.html . Accessed May 9, 2018.

National Center for Injury Prevention and Control. 10 leading causes of death by age group, United States—2015. https://www.cdc.gov/injury/images/lc-charts/leading_causes_of_death_age_group_2015_1050w740h.gif . Accessed April 24, 2017.

Durbin DR American Academy of Pediatrics Committee on Injury, Violence, and Poison Prevention. Child passenger safety. Pediatrics. 2011;127(4):788-793.

American Academy of Pediatrics Committee on Injury and Poison Prevention. Reducing the number of deaths and injuries from residential fires. Pediatrics. 2000;105(6):1355-1357.

Gardner HG American Academy of Pediatrics Committee on Injury, Violence, and Poison Prevention. Office-based counseling for unintentional injury prevention. Pediatrics. 2007;119(1):202-206.

American Academy of Pediatrics Committee on Injury, Violence, and Poison Prevention. Prevention of drowning in infants, children, and adolescents. Pediatrics. 2003;112(2):437-439.

American Academy of Pediatrics Committee on Injury and Poison Prevention. Injuries associated with infant walkers. Pediatrics. 2001;108(3):790-792.

American Academy of Pediatrics Committee on Injury and Poison Prevention. Falls from heights: windows, roofs, and balconies. Pediatrics. 2001;107(5):1188-1191.

Dowd MD, Sege RD Council on Injury, Violence, and Poison Prevention Executive Committee; American Academy of Pediatrics. Firearm-related injuries affecting the pediatric population. Pediatrics. 2012;130(5):e1416-e1423.

American Academy of Pediatrics Committee on Injury, Violence, and Poison Prevention. Prevention of choking among children. Pediatrics. 2010;125(3):601-607.

Kendrick D, Young B, Mason-Jones AJ, et al. Home safety education and provision of safety equipment for injury prevention (review). Evid Based Child Health. 2013;8(3):761-939.

American Academy of Pediatrics Section on Oral Health. Maintaining and improving the oral health of young children. Pediatrics. 2014;134(6):1224-1229.

Heyman MB, Abrams SA American Academy of Pediatrics Section on Gastroenterology, Hepatology, and Nutrition Committee on Nutrition. Fruit juice in infants, children, and adolescents: current recommendations. Pediatrics. 2017;139(6):e20170967.

Council on Communications and Media. Media and young minds. Pediatrics. 2016;138(5):e20162591.

Moon RY Task Force on Sudden Infant Death Syndrome. SIDS and other sleep-related infant deaths: evidence base for 2016 updated recommendations for a safe infant sleeping environment. Pediatrics. 2016;138(5):e20162940.

American Academy of Pediatrics Section on Breastfeeding. Breastfeeding and the use of human milk. Pediatrics. 2012;129(3):e827-e841.

Wagner CL, Greer FR American Academy of Pediatrics Section on Breastfeeding; Committee on Nutrition. Prevention of rickets and vitamin D deficiency in infants, children, and adolescents [published correction appears in Pediatrics . 2009;123(1):197]. Pediatrics. 2008;122(5):1142-1152.

Huh SY, Rifas-Shiman SL, Taveras EM, Oken E, Gillman MW. Timing of solid food introduction and risk of obesity in preschool-aged children. Pediatrics. 2011;127(3):e544-e551.

Greer FR, Sicherer SH, Burks AW American Academy of Pediatrics Committee on Nutrition; Section on Allergy and Immunology. Effects of early nutritional interventions on the development of atopic disease in infants and children: the role of maternal dietary restriction, breastfeeding, timing of introduction of complementary foods, and hydrolyzed formulas. Pediatrics. 2008;121(1):183-191.

American Academy of Pediatrics Committee on Nutrition. The use of whole cow's milk in infancy. Pediatrics. 1992;89(6 pt 1):1105-1109.

Fleischer DM, Spergel JM, Assa'ad AH, Pongracic JA. Primary prevention of allergic disease through nutritional interventions. J Allergy Clin Immunol Pract. 2013;1(1):29-36.

Grossman DC, Bibbins-Domingo K, Curry SJ, et al. Screening for obesity in children and adolescents: U.S. Preventive Services Task Force recommendation statement. JAMA. 2017;317(23):2417-2426.

Daniels SR, Hassink SG Committee on Nutrition. The role of the pediatrician in primary prevention of obesity. Pediatrics. 2015;136(1):e275-e292.

American Academy of Family Physicians. Physical activity in children. https://www.aafp.org/about/policies/all/physical-activity.html . Accessed January 1, 2018.

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Autotext Dot Phrases for Cerner EHR

All templates, "autotexts", procedure notes, and other documents on these pages are intended as examples only for educational purposes.  Your documentation in the medical record should always reflect precisely your specific interaction with an individual patient.  Do not merely copy and paste a prewritten note element into a patient's chart - "cloning" is unethical, unsafe, and potentially fradulent.

• venturafamilymed
• Sep 8, 2021

Well Child Check: 7 year old

SUBJECTIVE:

7 yo _ here for well child check. No parental or patient concerns at this time.

REVIEW OF SYSTEMS:

- Diet: No concerns.

- Fast food, soda, juice intake: _

- Calcium intake: _

- Voiding/stooling: No concerns.

- Dental: + brushes teeth. Sees the dentist regularly.

- Behavior: No concerns.

Normal pregnancy and delivery. No surgeries, hospitalizations, or serious illnesses to date.

DEVELOPMENT:

- In _ grade. School is going well.

- Has friends.

- After-school activities: _

- Physical activity (and safety): _

- Screen time: _

- Does chores when asked.

- Knows address and home phone number.

- Prints letters without problems.

- Noteworthy social stressors: _

- No smokers in the home.

- No TB or lead risk factors.

IMMUNIZATIONS:

- Up to date.

- VITALS: _

- GEN: Normal general appearance. NAD.

- HEAD: NCAT.

- EYES: PERRL, red reflex present bilaterally. Light reflex symmetric. EOMI.

- ENMT: TMs and nares normal. MMM. Normal gums, mucosa, palate, OP. Good dentition.

- NECK: Supple, with no masses.

- CV: RRR, no m/r/g.

- LUNGS: CTAB, no w/r/c.

- ABD: Soft, NT/ND, NBS, no masses or organomegaly.

- GU: Normal _male genitalia. Testes descended bilaterally.

- SKIN: WWP. No skin rashes or abnormal lesions.

- MSK: No deformities. Normal gait. No clubbing, cyanosis, or edema.

- NEURO: Normal muscle strength and tone. No focal deficits.

GROWTH CHART: Following growth curve well in all parameters. BMI at _ percentile.

LABS/STUDIES:

- Urine dip normal.

- Hearing screen normal.

- Snellen testing: _

ASSESSMENT/PLAN:

* Healthy 7 yo child

- CBC ordered. No indication for a lipid panel or DM screening.

- Follow up at 8 years of age, or sooner PRN.

- ER/return precautions discussed.

* Vaccines today:

- Influenza

* Anticipatory guidance (discussed or covered in a handout given to the family)

- Safety: Street safety, strangers, gun safety, helmets and safety equipment.

- Booster seat required by law until 8 yrs old or 4’9”

- Food and exercise: Limiting juice and junk/fast food, exercise.

- Memorize name, address, and phone number.

- School: Communicate with teachers, discuss peer pressure and bullying, internet safety.

- Speech: Importance of reading, limiting screen time.

- Dental care and fluoride; dental visits

- Hazards of second hand smoke

• Encounter Notes

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