|
N A Gen. appearance
___________________
N A Skin _____________________________
N A HEENT/teeth _____________________
N A Neck ____________________________
N A Lungs ____________________________
N A Heart ____________________________ |
N A Abdomen
___________________________
N A Genitalia ____________________________
N A Back _______________________________
N A Anorectal____________________________
N A Extremities __________________________
N A CNS________________________________
|
|
SCREENING: As age appropriate (see schedule):
Lead ______________________________
PPD ______________________________
IF RISK FACTORS
PRESENT:
Hematocrit or hemoglobin _____________
PLANS/ORDERS: As needed for age
IMMUNIZATIONS:
A. Immunizations
__ HBV __ Varicella
__ DTaP __ Pneumococcal/PVC
__ Hib __ PPD 0.1cc 5TU ID
__ IPV __ Other
__________
__ MMR
______________
B. Lab Test:
__ UA
__ CBC __Hgb Elect./Sickle prep
__ Hgb __Other
__ Lead
C. Developmental follow-up:
__ No delays noted: Routine follow-up
__ One or more "No" (or significant
concerns): Complete
Ages & Stages or
other developmental Screen, or call
COMPASS (below) for
referral to Early
ACCESS.
D. Other: ____________________________
_____________________________________
Patient education
provided:
__ Yes _________________________
Return to
clinic:
Plan for next
visit:
Nurse
Conference __ Yes __ No
__________________________________
Signature (MD/PNP/PA)
_____________________________________
CENTRAL REFERRAL for
developmental delay and or disability: COMPASS at
1-800-779-2001. |
NURSE
CONFERENCE: (medications,
tests, vaccines, nutrition, safety, anticipatory guidance, etc.)
___________________________________
_______________________________________
_______________________________________
_______________________________________
_________________________________
Signature (RN/LPN)
ASSESSMENTS: __
Well child __ Other
_____________________________________
_____________________________________
_____________________________________
_____________________________________
SUMMARY of visit:
_____________________________________
_____________________________________
_____________________________________
_____________________________________
Arrange
continuing care:
_____________________________________
_____________________________________
_____________________________________
_____________________________________
REFERRAL:
__ Health insurance __Social services
__ Care coordination __Housing
__ SSI __Dental visit
__ WIC __Food stamps
__ Other: ___________________________
___________________________
___________________________
NOTES:
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_____________________________________
_______________________________________
CENTRAL
REFERRAL for other care coordination,
transportation, or health information: Iowa Healthy
Families, 1-800-369-2229. |
