Tài liệu Practice Guidelines 2013 Pediatric Well Child Care Flow Sheets ppt

Health care benefit programs issued or administered by Capital BlueCross and/or its subsidiaries, Capital Advantage Insurance
Company
®
, Capital Advantage Assurance Company
®
and Keystone Health Plan
®
Central. Independent licensees of the BlueCross
BlueShield Association. Communications issued by Capital BlueCross in its capacity as administrator of programs and provider relations
for all companies.


















Practice
Guidelines

2013



Pediatric Well Child Care Flow Sheets





PHYSICIAN GUIDELINES FOR PREVENTIVE SERVICES

Capital BlueCross’ Physician Guidelines for Preventive Services should serve as a useful
component of your delivery of preventive services. We urge you to refer to them frequently
and aim for the highest compliance possible. Additional suggestions follow:

 Make preventive services one of your practice’s highest priorities.

 Consider every visit as an opportunity to promote wellness services.

 If time and resources are especially scarce, try devoting attention to at least a few key
areas on a seasonal basis.

 Post a copy of the Guidelines in each consultation/exam room.

 Reinforce our efforts to educate Members about the importance of health
maintenance interventions.

 Use office reminder systems, including wall posters and chart alerts.

 Involve non-physician staff in the process, including the delegation of specific
responsibilities.


The Guidelines include:

Adult Health Maintenance Guidelines (Commercial)

Adult Health Maintenance Guidelines (SeniorBlue and SeniorBlue PPO)

Child Health Maintenance Guidelines
Pediatric Well Child Care Flow Sheets


PEDIATRIC WELL CHILD CARE

PATIENT’S NAME: ______________________________

2/94; REV.: 1/97; 3/98, 3/99, 5/02, 4/04, 6/05, 3/08, 4/09, 3/10, 4/12 T:\QM\TRANSFER\FORMS\PED CHART REVISED 6-05.DOC LAST PRINTED 5/30/2012 2:03:00 PM

Health care benefit programs issued or administered by Capital BlueCross and/or its subsidiaries, Capital Advantage Insurance Company
®
®
and Keystone Health
Plan
®
®

Central. Independent licensees of the Blue Cross and Blue Shield Association. Communications issued by Capital BlueCross in its capacity as administrator
of programs and provider relations for all companies.

DEVELOPMENTAL TASKS
PRESENT
NORMAL ABNORMAL
(DESCRIBE BELOW)

NUTRITION
ANTICIPATORY GUIDANCE AND
SAFETY
2-4 Weeks
Equal Movements
Length Wt.
HC
Breast
Car restraints

Palmar grasp
General Appearance
Formula
Crib safety
Date of Visit
Raises head when prone
Skin
Fem. Art.

Sleep position

Regards face

Head
Abdomen

Babysitters

Follows to midline
Responds to sound
Fontanelle
Eyes
Umbilic
Genitalia

Pet control
Secondary tobacco smoke


Red Reflex
Testes

Tap water not to exceed 120F

Follow-up on abnormal
ENT
Extrem

for bathing

Newborn Screens
Lungs
Hips

Smoke detectors


Heart
Neuro

Vitamins (breast-fed babies)





Coughs/colds




Urine

Comments:
Abnormalities:

Stools

Return_____________




Provider Initials______


DEVELOPMENTAL TASKS
PRESENT
NORMAL ABNORMAL
(DESCRIBE BELOW)

NUTRITION
ANTICIPATORY GUIDANCE AND
SAFETY
1 Month
Equal Movements
Length Wt.
HC
Breast
Car restraints

Palmar grasp
General Appearance
Formula

Crib safety
Date of Visit
Raises head when prone
Skin
Fem. Art.

Sleep position

Regards face
Head
Abdomen

Babysitters

Follows to midline
Responds to sound
Fontanelle
Eyes
Umbilic
Genitalia

Pet control
Secondary tobacco smoke


Red Reflex
Testes

Tap water not to exceed 120F

ENT
Extrem

for bathing


Lungs
Hips

Smoke detectors


Heart
Neuro

Coughs/colds










Urine
Immunizations:
Comments:

Abnormalities:

Stools










Return_____________




Provider Initials______


DEVELOPMENTAL TASKS
PRESENT
NORMAL ABNORMAL
(DESCRIBE BELOW)

NUTRITION
ANTICIPATORY GUIDANCE AND
SAFETY
2 Months

Lifts head temp. erect
Length Wt.
HC
Breast
Sleep patterns

when held upright
General Appearance
Formula
Daycare / babysitters
Date of Visit
Regards face in direct line
Skin
Fem Art.

Sleep position

of vision
Grasps rattle placed in
hand
Head
Fontanelle
Eyes
Abdomen
Genitalia
Testes

Fall prevention
Coughs/colds

Social smile
Coos
ENT
Lungs
Extrem
Hips



Responds to sound
Heart
Neuro













Immunizations:

Urine

Comments:
Abnormalities:

Stools










Return_____________




Provider Initials______







PEDIATRIC WELL CHILD CARE

PATIENT’S NAME: ______________________________

2/94; REV.: 1/97; 3/98, 3/99, 5/02, 4/04, 6/05, 3/08, 4/09, 3/10, 4/12 T:\QM\TRANSFER\FORMS\PED CHART REVISED 6-05.DOC LAST PRINTED 5/30/2012 2:03:00 PM

Health care benefit programs issued or administered by Capital BlueCross and/or its subsidiaries, Capital Advantage Insurance Company
®
®
and Keystone Health
Plan
®
®
Central. Independent licensees of the Blue Cross and Blue Shield Association. Communications issued by Capital BlueCross in its capacity as administrator
of programs and provider relations for all companies.

DEVELOPMENTAL TASKS
PRESENT
NORMAL ABNORMAL
(DESCRIBE BELOW)

NUTRITION
ANTICIPATORY GUIDANCE AND
SAFETY
4 Months
Holds head high
Length Wt.
HC
Breast
Sleep position

Raises body on hands
General Appearance
Formula
Reinforce falls prevention
Date of Visit
when prone
Skin
Heart

Avoid small objects

Rolls prone to supine
Plays with hands
Follows parent with eyes
Eyes
Head
Fontanelle
Fem Art.
Abdomen
Genitalia

Coughs/colds

Smiles, coos, laughs,
squeals, gurgles
ENT
Lungs
Extrem
Hips
Cereal

Neuro







Immunizations:
Comments:
Abnormalities:

Stools










Return_____________

Provider Initials______






DEVELOPMENTAL TASKS
PRESENT
NORMAL ABNORMAL
(DESCRIBE BELOW)

NUTRITION
ANTICIPATORY GUIDANCE AND
SAFETY
6 Months
Sits with support
Length Wt.
HC
Breast


Passes hand to hand
General Appearance
Formula
Check home for hazards
Date of Visit
Rolls over

Head
Heart

hot liquids, electrical outlets,

Reaches for toys
Bears weight
Raking hand pattern
Babbles, laughs
Fontanelle
Skin
EOM
ENT
Fem Art.
Abdomen
Genitalia
Extrem

poisons, medicines, dangling
cords or table covers
Provide Poison Control phone #

Turns to voice

Eyes
Teeth
Hips
Neuro
Puréed foods
(including

Sleep position
Sun exposure


Lungs

iron sources)
Crib safety




Fluoride
Car restraints





Coughs/colds

Comments:
Abnormalities:


Immunizations:

Return_____________




Provider Initials______






DEVELOPMENTAL TASKS
PRESENT
NORMAL ABNORMAL
(DESCRIBE BELOW)

NUTRITION
ANTICIPATORY GUIDANCE AND
SAFETY
9 Months
Sits well
Length Wt.
HC
Breast

Home safety

Crawls, creeps
General Appearance
Formula
Avoid popcorn, nuts, raw carrot
Date of Visit
Pulls to stand
Head
Heart
Table Food
or celery sticks, raw apple, raisins

Assisted walking
Inferior pincer grasps -
pokes
Fontanelle
Skin
ENT
Abdomen
Genitalia
Neuro

or tiny pieces of toys
Family/social dynamics
Sun exposure

Bangs two toys together
Pat-a-cake
Peek-a-boo

Imitates speech sounds
“Dada” Mama”
Eyes
Teeth
Lungs
Extrem
Hips
Self-feeding
Toast
Teething bisc.
Wean to cup
Fluoride
Tooth care
Car restraints
Coughs/colds





Immunizations:






Comments:
Abnormalities:

Stools





Return_____________




Provider Initials______







PEDIATRIC WELL CHILD CARE

PATIENT’S NAME: ______________________________

2/94; REV.: 1/97; 3/98, 3/99, 5/02, 4/04, 6/05, 3/08, 4/09, 3/10, 4/12 T:\QM\TRANSFER\FORMS\PED CHART REVISED 6-05.DOC LAST PRINTED 5/30/2012 2:03:00 PM

Health care benefit programs issued or administered by Capital BlueCross and/or its subsidiaries, Capital Advantage Insurance Company
®
®
and Keystone Health
Plan

®
®
Central. Independent licensees of the Blue Cross and Blue Shield Association. Communications issued by Capital BlueCross in its capacity as administrator
of programs and provider relations for all companies.

DEVELOPMENTAL TASKS
PRESENT
NORMAL ABNORMAL
(DESCRIBE BELOW)

NUTRITION
ANTICIPATORY GUIDANCE AND
SAFETY
12 Months
Pulls to stand
Length Wt.
HC
Breast
SAFETY poison-proofing;

Walks w/support or few
General Appearance
Milk
stair safety, water safety, auto seat
Date of Visit
steps alone
Head
Heart
(whole milk)
restraints; fences and gates

Precise pincer grasp
Points
Has 1-3 new words plus
Fontanelle
Skin
ENT
Abdomen
Genitalia
Extrem
Table foods
Continue
weaning
Tooth care
Sun exposure
Coughs/colds

“Dada” “Mama”
Looks for dropped or
hidden objects
Eyes
Teeth
Lungs
Hips
Neuro
to cup

MVI
Immunizations:
Comments:
Abnormalities:

Fluoride










Return_____________




Provider Initials______

DEVELOPMENTAL TASKS
PRESENT
NORMAL ABNORMAL
(DESCRIBE BELOW)

NUTRITION
ANTICIPATORY GUIDANCE
AND SAFETY
15 Months
Walks alone
Length Wt.
HC
Milk
REEMPHASIZE:

Crawls up stairs
Puts raisin in bottle
General Appearance
Skin Fem Art.
Toothcare
No bottle in
Home/environment safety
Socialization
Date of Visit
Points to 1-2 body parts

Eyes
Abdomen
bed
Tantrums/behavior

Gestures
Understands simple
commands
Head
Fontanelle
ENT
Genitalia
Testes
Extrem
Finger foods
Fluoride
Sun exposure
Coughs/colds

Uses cup
Teeth
Lungs
Gait
Neuro
MVI



Heart

Immunizations:
Comments:
Abnormalities:












Return_____________




Provider Initials______






DEVELOPMENTAL TASKS
PRESENT

NORMAL ABNORMAL
(DESCRIBE BELOW)

NUTRITION
ANTICIPATORY GUIDANCE
AND SAFETY
18 Months
Walks up stairs with help
Length Wt.
HC
Mealtime not
STRESS FIRMLY:

Sits in a chair
General Appearance
to be a battle
Stairs & window safety
Date of Visit
3-4 Cube tower
Uses spoon
Head
Fontanelle
Abdomen
Genitalia
Discourage
snacks
Avoid playing in street/driveway
Coughs/colds

Imitates a crayon stroke

4-10 words
May tell 2 or more wants
Skin
Eyes
ENT
Testes
Extrem
Gait
Toothcare
Fluoride
Don’t leave alone in car or home
Guard against falls, electrical
injuries, drowning

Knows body parts
Autism screening
Teeth
Lungs
Neuro

MVI
Sleep patterns & night fears
Toothbrushing


Heart


Sun exposure

Comments:
Abnormalities:


Immunizations:









Return_____________




Provider Initials______







PEDIATRIC WELL CHILD CARE

PATIENT’S NAME: ______________________________

2/94; REV.: 1/97; 3/98, 3/99, 5/02, 4/04, 6/05, 3/08, 4/09, 3/10, 4/12 T:\QM\TRANSFER\FORMS\PED CHART REVISED 6-05.DOC LAST PRINTED 5/30/2012 2:03:00 PM

Health care benefit programs issued or administered by Capital BlueCross and/or its subsidiaries, Capital Advantage Insurance Company
®
®
and Keystone Health
Plan
®
®
Central. Independent licensees of the Blue Cross and Blue Shield Association. Communications issued by Capital BlueCross in its capacity as administrator
of programs and provider relations for all companies.

DEVELOPMENTAL TASKS
PRESENT
NORMAL ABNORMAL
(DESCRIBE BELOW)

NUTRITION
ANTICIPATORY GUIDANCE
AND SAFETY
24 Months
Walks up steps
Ht. Wt.
HC
Avoid fights
STRESS DANGERS: Burns, falls

Jumps in place
Sits in a chair

General BMI
Skin Lungs
Over eating
No snacks
from windows, cabinets, furniture;
eat and drink when sitting; poison
Date of Visit
5-6 Cube tower
Eyes
Heart
Fluoride
danger; avoid machinery, plastic

Makes horizontal or
circular strokes
50+ Words
Knows name
Head
ENT
Hearing
Vision
Abdomen
Genitalia
Extrem
Neuro
MVI
bags
Read to child
Toilet training
Sun exposure

“What’s that?”
Parents understand child’s
Teeth




Poison control information
Coughs/colds

speech





Autism screening



Immunizations:
Comments:
Abnormalities:

Return_____________




Provider Initials______

DEVELOPMENTAL TASKS
PRESENT
NORMAL ABNORMAL
(DESCRIBE BELOW)

NUTRITION
ANTICIPATORY GUIDANCE
AND SAFETY
30 Months
Walks up steps
Ht. Wt.
HC
Avoid fights
STRESS DANGERS: Burns, falls

Jumps in place
Sits in a chair
General BMI
Skin Lungs
Over eating
No snacks
from windows, cabinets, furniture;

eat and drink when sitting; poison
Date of Visit
5-6 Cube tower
Eyes
Heart
Fluoride
danger; avoid machinery, plastic

Makes horizontal or
circular strokes
50+ Words
Knows name
Head
ENT
Hearing
Vision
Abdomen
Genitalia
Extrem
Neuro
MVI
bags
Read to child
Toilet training
Sun exposure

“What’s that?”
Parents understand child’s
Teeth

Poison control information
Coughs/colds

speech





Able to pedal



Immunizations:
Comments:
Abnormalities:







Return_____________

Provider Initials______






DEVELOPMENTAL TASKS
PRESENT
NORMAL ABNORMAL
(DESCRIBE BELOW)

NUTRITION
ANTICIPATORY GUIDANCE
AND SAFETY
3 Years
Kicks ball
Ht. Wt.
BP
Avoid junk
Car seat

Pedals tricycle
Opens door
General BMI
Skin Teeth
drinks & food
Feeds self
Knives out of reach

Stay out of streets
Date of Visit
9 Cube tower
Head
Lungs
entirely
Water safety

Copies circle
Does some dressing
Feeds self
Eyes
ENT
EOM
Heart
Abdomen
Back

Read to child
Speech or language evaluation
Sun exposure

Knows full name, age, sex
Counts to three
Comprehends “tired,
“cold,” “hungry”
Vision test

Genitalia
Extrem

Neuro
Dental care &
referral
Fluoride
Coughs/colds


Immunizations:




MVI

Comments:
Abnormalities:







Return_____________




Provider Initials______

PEDIATRIC WELL CHILD CARE

PATIENT’S NAME: ______________________________

2/94; REV.: 1/97; 3/98, 3/99, 5/02, 4/04, 6/05, 3/08, 4/09, 3/10, 4/12 T:\QM\TRANSFER\FORMS\PED CHART REVISED 6-05.DOC LAST PRINTED 5/30/2012 2:03:00 PM

Health care benefit programs issued or administered by Capital BlueCross and/or its subsidiaries, Capital Advantage Insurance Company
®
®
and Keystone Health
Plan
®
®
Central. Independent licensees of the Blue Cross and Blue Shield Association. Communications issued by Capital BlueCross in its capacity as administrator
of programs and provider relations for all companies.

DEVELOPMENTAL TASKS
PRESENT
NORMAL ABNORMAL
(DESCRIBE BELOW)

NUTRITION
ANTICIPATORY GUIDANCE
AND SAFETY

4 Years
Hops, jumps forward
Ht. Wt.
BP
Family talk
REEMPHASIZE: Water safety;

Climbs ladder
Can cut & paste
General BMI
Skin Teeth
mealtimes
Offer small
street crossing and/or play;
booster seat, and/or appropriate
Date of Visit
Knows 3 or 4 colors
Head
Lungs
portions
seat belt placement; avoid

Dresses & undresses
w/supervision
Counts to 10
Gender ID
Eyes
EOM
ENT
Vision test

Heart
Abdomen
Back
Neuro
Seconds
available
strangers; home fire safety;
sleep in own bed
Sun exposure
Marble & card games; bed time

Draws person - 3 parts
Copies cross, circle &
maybe square

Genitalia
Extrem
Dental care
Fluoride
ritual; nursery school, daycare,
babysitting
Car booster seat




MVI
Bike helmet
Coughs/colds

Immunizations:
Comments:
Abnormalities:












Return_____________




Provider Initials______

DEVELOPMENTAL TASKS
PRESENT
NORMAL ABNORMAL
(DESCRIBE BELOW)

NUTRITION
ANTICIPATORY GUIDANCE
AND SAFETY
5 Years
Hops on one foot
Ht. Wt.
BP
Balanced diet
Seat belts

Dresses & undresses self
Can throw and catch a
General BMI
Skin Teeth

Street sense
School experiences/readiness
Date of Visit
bean bag
Head
Lungs

Separates from parents

Gallops, begins skipping,
alterntaing feet
Prints some letters and
numbers
Eyes
EOM
ENT
Heart
Abdomen
Back
Neuro

Family dynamics
Bike helmet
Car booster seat
Sun exposure



Vision test
Genitalia
Extrem
Dental care
Fluoride



Hearing test

MVI






Immunizations:
Comments:
Abnormalities:












Return_____________




Provider Initials______

DEVELOPMENTAL TASKS
PRESENT
NORMAL ABNORMAL
(DESCRIBE BELOW)

NUTRITION
ANTICIPATORY GUIDANCE
AND SAFETY
6 Years
Rides bicycle
Ht. Wt.
BP
Balanced diet
Bike/traffic safety

Laces and ties shoes
Growing capacity for self-
General BMI
Skin Teeth
Monitor
snacks
Home environment
School environment
Date of Visit
regulation of behavior
Head

Lungs

Car booster seat

Can answer phone, take
simple messages
School experiences
Eyes
EOM
ENT
Heart
Abdom
Back

Sun exposure
Firearm safety
Exercise



Vision test
Genit
Extrem
Dental care
Fluoride



Hearing test
Neuro

MVI
Immunizations:
Comments:
Abnormalities:












Return_____________




Provider Initials______







PEDIATRIC WELL CHILD CARE

PATIENT’S NAME: ______________________________

2/94; REV.: 1/97; 3/98, 3/99, 5/02, 4/04, 6/05, 3/08, 4/09, 3/10, 4/12 T:\QM\TRANSFER\FORMS\PED CHART REVISED 6-05.DOC LAST PRINTED 5/30/2012 2:03:00 PM

Health care benefit programs issued or administered by Capital BlueCross and/or its subsidiaries, Capital Advantage Insurance Company
®
®
and Keystone Health
Plan
®
®
Central. Independent licensees of the Blue Cross and Blue Shield Association. Communications issued by Capital BlueCross in its capacity as administrator
of programs and provider relations for all companies.

DEVELOPMENTAL TASKS
PRESENT
NORMAL ABNORMAL
(DESCRIBE BELOW)

NUTRITION
ANTICIPATORY GUIDANCE
AND SAFETY
7 Years
Rides bicycle
Ht. Wt.
BP
Balanced diet
Bike/traffic safety

Laces and ties shoes
Growing capacity for self-
General BMI
Skin Teeth
Monitor
snacks
Home environment
School environment
Date of Visit
regulation of behavior
Head
Lungs

Car booster seat

Can answer phone, take
simple messages
School experiences
Eyes
EOM
ENT
Heart
Abdom
Back

Sun exposure
Firearm safety
Exercise

Vision test
Genit
Extrem
Dental care
Fluoride



Hearing test
Neuro
MVI
Immunizations:
Comments:
Abnormalities:












Return_____________

Provider Initials______






DEVELOPMENTAL TASKS
PRESENT
NORMAL ABNORMAL
(DESCRIBE BELOW)

NUTRITION
ANTICIPATORY GUIDANCE
AND SAFETY
8 Years
Physical/skills develop
Ht. Wt.
BP
Balanced diet
Illicit drugs/alcohol/tobacco

Emotional development
Intellectual development
General BMI
Skin Genitalia
Monitor
snacks

Home environment
Puberty
Date of Visit
Social development
HEENT
Extrem

Exercise

Community
Interests
Teeth
Nodes
Chest
Back
Neuro


Peer pressure
Family dynamics
Seat belt placement


Heart
Abdomen
Vision test
Dental care
Fluoride
Sun exposure
Firearm safety

Comments:
Abnormalities:

MVI
Immunizations:









Return_____________




Provider Initials______






DEVELOPMENTAL TASKS
PRESENT
NORMAL ABNORMAL
(DESCRIBE BELOW)

NUTRITION
ANTICIPATORY GUIDANCE
AND SAFETY
9 Years
Physical/skills develop
Ht. Wt.
BP
Balanced diet
Illicit drugs/alcohol/tobacco

Emotional development
Intellectual development
General BMI
Skin Genitalia
Monitor
snacks
Home environment
Puberty
Date of Visit
Social development
HEENT
Extrem

Exercise

Community
Interests
Teeth
Nodes

Chest
Back
Neuro


Peer pressure
Family dynamics
Seat belt placement


Heart
Abdomen
Vision test
Dental care
Fluoride
Sun exposure
Firearm safety
Comments:
Abnormalities:

MVI
Immunizations:

Return_____________




Provider Initials______







PEDIATRIC WELL CHILD CARE

PATIENT’S NAME: ______________________________

2/94; REV.: 1/97; 3/98, 3/99, 5/02, 4/04, 6/05, 3/08, 4/09, 3/10, 4/12 T:\QM\TRANSFER\FORMS\PED CHART REVISED 6-05.DOC LAST PRINTED 5/30/2012 2:03:00 PM

Health care benefit programs issued or administered by Capital BlueCross and/or its subsidiaries, Capital Advantage Insurance Company
®
®
and Keystone Health
Plan
®
®
Central. Independent licensees of the Blue Cross and Blue Shield Association. Communications issued by Capital BlueCross in its capacity as administrator
of programs and provider relations for all companies.

DEVELOPMENTAL TASKS
PRESENT
NORMAL ABNORMAL
(DESCRIBE BELOW)

NUTRITION
ANTICIPATORY GUIDANCE
AND SAFETY
10 Years
Physical/skills develop
Ht. Wt.
BP
Balanced diet
Illicit drugs/alcohol/tobacco

Emotional development
Intellectual development
General BMI
Skin Genitalia
Monitor
snacks
Home environment
Puberty
Date of Visit
Social development
HEENT
Extrem

Exercise

Community
Interests
Teeth
Nodes
Chest
Back
Neuro


Peer pressure
Family dynamics
Seat belt placement


Heart
Abdomen

Vision test
Dental care
Fluoride
Sun exposure
Firearm safety
Comments:
Abnormalities:

MVI
Immunizations:

Return_____________




Provider Initials______






DEVELOPMENTAL TASKS
PRESENT
NORMAL ABNORMAL
(DESCRIBE BELOW)

NUTRITION
ANTICIPATORY GUIDANCE
AND SAFETY
11 Years
Physical/skills develop
Ht. Wt.
BP

Balanced diet
Illicit drugs/alcohol/tobacco

Emotional development
Intellectual development
General BMI
Skin Genitalia
Monitor
snacks
Home environment
Puberty
Date of Visit
Social development
HEENT
Extrem

Exercise

Community
Interests
Teeth
Nodes
Chest
Back
Neuro


Peer pressure
Family dynamics
Seat belt placement

Heart
Abdomen

Vision
test
Dental care
Fluoride
Sun exposure
Firearm safety
Comments:
Abnormalities:

MVI
Immunizations:









Return_____________

Provider Initials______






DEVELOPMENTAL TASKS
PRESENT
NORMAL ABNORMAL
(DESCRIBE BELOW)

NUTRITION
ANTICIPATORY GUIDANCE
AND SAFETY
12 Years
Physical/skills develop
Ht. Wt.
BP
Balanced diet
Illicit drugs/alcohol/tobacco

Emotional development
Intellectual development
General BMI
Skin Genitalia
Monitor
snacks
Home environment
Puberty

Date of Visit
Social development
HEENT
Extrem

Exercise

Community
Interests
Teeth
Nodes
Chest
Back
Neuro


Peer pressure
Family dynamics
Seat belt placement


Heart
Abdomen

Vision
test
Dental care
Fluoride
Sun exposure
Firearm safety

Comments:
Abnormalities:

MVI
Immunizations:









Return_____________




Provider Initials______







PEDIATRIC WELL CHILD CARE

PATIENT’S NAME: ______________________________

2/94; REV.: 1/97; 3/98, 3/99, 5/02, 4/04, 6/05, 3/08, 4/09, 3/10, 4/12 T:\QM\TRANSFER\FORMS\PED CHART REVISED 6-05.DOC LAST PRINTED 5/30/2012 2:03:00 PM

Health care benefit programs issued or administered by Capital BlueCross and/or its subsidiaries, Capital Advantage Insurance Company
®
®
and Keystone Health
Plan
®
®
Central. Independent licensees of the Blue Cross and Blue Shield Association. Communications issued by Capital BlueCross in its capacity as administrator
of programs and provider relations for all companies.

DEVELOPMENTAL TASKS
PRESENT
NORMAL ABNORMAL
(DESCRIBE BELOW)

NUTRITION
ANTICIPATORY GUIDANCE
AND SAFETY
13 Years
Physical/skills develop
Ht. Wt.
BP
Balanced diet
Illicit drugs/alcohol/tobacco

Emotional development
Intellectual development

General BMI
Skin Genitalia
Monitor
snacks
Home environment
Puberty
Date of Visit
Social development
HEENT
Extrem

Exercise

Community
Interests
Teeth
Nodes
Chest
Back
Neuro


Peer pressure
Family dynamics
Seat belt placement


Heart
Abdomen
Vision

test
Dental care
Fluoride
Sun exposure
Firearm safety
Comments:
Abnormalities:

MVI
Immunizations:









Return_____________




Provider Initials______

DEVELOPMENTAL TASKS
PRESENT
NORMAL ABNORMAL
(DESCRIBE BELOW)

NUTRITION
ANTICIPATORY GUIDANCE
AND SAFETY
14 Years
Physical/skills develop
Ht. Wt.
BP
Cholesterol
Illicit drugs/alcohol/tobacco

Emotional development
Education
General
Skin
BMI
Extrem

Exercise
Injury prevention; firearms
Date of Visit
Social relationships
HEENT
Back
MVI

Nutrition


Teeth
Nodes
Chest
Genitalia
Neuro


Pregnancy prevention
Sexually transmitted diseases
TSE/BSE


Heart
Abdomen
Vision
test
Dental care

Sun exposure
Chlamydia/STD screening


Pelvic exam
Pap

Immunizations:
Comments:

Abnormalities:












Return_____________




Provider Initials______






DEVELOPMENTAL TASKS
PRESENT
NORMAL ABNORMAL
(DESCRIBE BELOW)

NUTRITION
ANTICIPATORY GUIDANCE
AND SAFETY
15 Years
Physical/skills develop
Ht. Wt.
BP
Cholesterol
Illicit drugs/alcohol/tobacco

Emotional development
Education
General
Skin
BMI
Extrem
evaluation
Exercise
Injury prevention; firearms
Date of Visit
Social relationships
HEENT
Back
MVI
Nutrition


Teeth
Nodes
Chest

Genitalia
Neuro


Pregnancy prevention
Sexually transmitted diseases
TSE/BSE


Heart
Abdomen
Vision
test
Dental care

Sun exposure
Chlamydia/STD screening


Pelvic exam
Pap

Immunizations:
Comments:
Abnormalities:

Return_____________




Provider Initials______







PEDIATRIC WELL CHILD CARE

PATIENT’S NAME: ______________________________

2/94; REV.: 1/97; 3/98, 3/99, 5/02, 4/04, 6/05, 3/08, 4/09, 3/10, 4/12 T:\QM\TRANSFER\FORMS\PED CHART REVISED 6-05.DOC LAST PRINTED 5/30/2012 2:03:00 PM

Health care benefit programs issued or administered by Capital BlueCross and/or its subsidiaries, Capital Advantage Insurance Company
®
®
and Keystone Health

Plan
®
®
Central. Independent licensees of the Blue Cross and Blue Shield Association. Communications issued by Capital BlueCross in its capacity as administrator
of programs and provider relations for all companies.

DEVELOPMENTAL TASKS
PRESENT
NORMAL ABNORMAL
(DESCRIBE BELOW)

NUTRITION
ANTICIPATORY GUIDANCE
AND SAFETY
16 Years
Physical/skills develop
Ht. Wt.
BP
Cholesterol
Illicit drugs/alcohol/tobacco

Emotional development
Education
General
Skin
BMI
Extrem
evaluation
Exercise
Injury prevention; firearms

Date of Visit
Social relationships
HEENT
Back
MVI
Nutrition


Teeth
Nodes
Chest
Genitalia
Neuro


Pregnancy prevention
Sexually transmitted diseases
TSE/BSE


Heart
Abdomen
Vision
test
Dental care

Sun exposure
Chlamydia/STD screening

Pelvic exam
Pap

Immunizations:
Comments:
Abnormalities:












Return_____________




Provider Initials______

DEVELOPMENTAL TASKS
PRESENT
NORMAL ABNORMAL
(DESCRIBE BELOW)

NUTRITION
ANTICIPATORY GUIDANCE
AND SAFETY
17 Years
Physical/skills develop
Ht. Wt.
BP
Cholesterol
Illicit drugs/alcohol/tobacco

Emotional development
Education
General
Skin
BMI
Extrem
evaluation
Exercise
Injury prevention; firearms
Date of Visit
Social relationships
HEENT
Back
MVI
Nutrition

Teeth
Nodes
Chest
Genitalia
Neuro


Pregnancy prevention
Sexually transmitted diseases
TSE/BSE


Heart
Abdomen
Vision
test
Dental care

Sun exposure
Chlamydia/STD screening


Pelvic exam
Pap

Immunizations:
Comments:
Abnormalities:

Return_____________




Provider Initials______






DEVELOPMENTAL TASKS
PRESENT
NORMAL ABNORMAL
(DESCRIBE BELOW)

NUTRITION

ANTICIPATORY GUIDANCE
AND SAFETY
18 Years
Physical/skills develop
Ht. Wt.
BP
Cholesterol
Illicit drugs/alcohol/tobacco

Emotional development
Education
General
Skin
BMI
Extrem
evaluation
Exercise
Injury prevention; firearms
Date of Visit
Social relationships
HEENT
Back
MVI
Nutrition


Teeth
Neuro

Pregnancy prevention

Nodes


Sexually transmitted diseases


Chest
Heart
Vision
test

TSE/BSE
Chlamydia/STD screening


Abdomen

Dental care
Sun exposure


Genitalia





Pelvic exam

Pap

Immunizations:
Comments:
Abnormalities:












Return_____________




Provider Initials______