Visit Documentation Form: 2 Month Visit

Visit Documentation Form: First Week Visit (3 to 5 Days)

Name

ID number

Date of Birth

Age

Accompanied By

Preferred Language

Date and Time

Weight (%)

Length (%)

HC (%)

Vital if (Indicated)

Temp

Resp Rate

Spo2

HISTORY

Concerns and Questions

Interval History

Medical History

Infant has special Areas reviewed and updated as needed

Past Medical History (See Initial History Questionnaire.)

Surgical History (See Initial History Questionnaire.

Problem List (See Problem List.)

Medications

No known drug allergies

Reviewed and updated (See Medication Record.)

Allergies

No known drug allergies

SCREENING RESULTS

Newborn blood screening

Normal

Abnormal

Newborn hearing screening

Passed BL Referred

If Referred, by?

Nutrition

Breast Milk

Formula

Add new row

Problems with bottle-feeding

Elimination

Regular soft stools

Normal urine stream

Sleep

Normal pattern

On Back

Safe sleep surface

Behavior

Activity (tummy time)

DEVELOPMENT

Normal development

See Pre-visit Questionnaire.

If yes, specify

SOCIAL LANGUAGE AND SELF-HELP

VERBAL LANGUAGE

GROSS MOTOR

SOCIAL LANGUAGE AND SELF-HELP

Smiles responsively (ie, social smile)

Vocalizes with simple cooing

Lifts head and chest in prone

Opens and shuts hands

SOCIAL AND FAMILY HISTORY

Areas reviewed and updated as needed (See Initial History Questionnaire.)

Social History

Family History

Changes since last visit

Smoking household

Yes

If yes, Specify

Parental support and work-family balance

Observation of parent-infant interaction

REVIEW OF SYSTEMS

A 10-point review of systems was performed and results were negative except for any positive results listed below.

Required Field = Focus area for this Bright Futures Visit

Constitutional

Respiratory

Skin

Eyes

Gastrointestinal

Neurological

Head, Ears, Nose, and Throat

Genitourinary

Other

Cardiovascular

Musculoskeletal

Other

PHYSICAL EXAMINATION

Required Field = Focus area for this Bright Futures Visit

General: Alert, active infant. Normal interval growth in height, weight, and head circumference. Normal weight-for-length for age

Head: Normocephalic and atraumatic. No positional skull deformities. Anterior fontanelle open and flat

Eyes: Fixes and follows. Red reflex present bilaterally. No opacification. Normal funduscopic examination findings

Ears, nose, and throat: Tympanic membranes with visible light reflex bilaterally. No oral lesions or thrush.

Neck: Supple, with full range of motion without torticollis

Heart: Regular rate and rhythm. No murmur. Symmetrical femoral pulses.

Respiratory: Breath sounds clear bilaterally. Comfortable work of breathing

Abdomen: Soft, with no palpable masses

Genitourinary:

Normal female external genitalia

Normal male external genitalia, with testes palpable in scrotum bilaterally

Musculoskeletal: Spine straight. Negative Ortolani and Barlow maneuvers

Neurological: Moves all extremities symmetrically. Normal strength and tone.

Skin: Warm and well perfused. No lesions, birthmarks, or bruising

Other comments

ASSESSMENT

Well child

Normal interval growth (See growth chart.)

Age-appropriate development

ANTICIPATORY GUIDANCE (Discussed and/or handout given )

SOCIAL DETERMINANTS OF HEALTH

PARENT AND FAMILY HEALTH

SAFETY

Living situation and food security
Family support
Child Care

Postpartum checkup
Maternal depression
Sibling relationships

Car safety seats
Safe sleep
Safe home environment: burns, drowning, and falls

NUTRITION AND FEEDING

INFANT BEHAVIOR AND DEVELOPMENT

General guidance on feeding and delaying solid foods
Hunger and satiety cues
Breastfeeding or formula-feeding guidance

Parent-infant relationship
Parent-infant communications
Sleeping
Media
Playtime
Fussiness

PLAN

(Immunization) Vaccine Administration Record reviewed

Administered today

Up-to-date for age

Universal Screening

Maternal depression: Screening tool used

Please explain

Newborn blood screening

Result

Pending

Normal

Needs Follow Up

Newborn hearing screening

Result

Passed BL

Referred right/left/BL

Needs follow-up

Selective Screening (based on risk assessment) (See Previsit Questionnaire.):

Vision

Comments/results:

Follow-up

Routine follow-up at 4 month

Next visit

Referral to

Next Visit

Referral to

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