Developmental-Behavioral Pediatrics Follow-Up Note

Date: [date of service]

Setting: [in-person / telehealth] (If telehealth, note any exam limitations.)

Participants: [patient and others present]

Historian(s): [who provided history—parent, guardian, patient, teacher form, therapist report, etc.]

Chief Concern

[Reason for follow-up and family priorities]. Follow-up since last DBP visit on [date of last visit].

Interval History

[Narrative summary of major changes since last visit]

• Symptoms/Function: [Current status of target symptoms across settings, attributed to source] (Include attention, behavior, emotional regulation, social communication, adaptive skills, and safety concerns as applicable.)
• Medication: [For each medication: name, dose/timing, adherence, response to target symptoms, side effects assessed including appetite, sleep, and mood] (Document even for refills.)
• School: [Placement, IEP/504 status, services, academic and behavioral functioning, recent concerns] (Note if not in school and why.)
• Therapies/Supports: [Active services—type, frequency, response] (Do not re-list unchanged historical services.)
• Collateral Reviewed: [Rating scales, school documents, therapy notes reviewed with name, date, source]

(If clinically relevant information is unavailable, document as "not obtained" with reason.)

Objective

Vitals/Growth: [height, weight, BMI, percentiles, BP/HR if relevant to medication management] (For telehealth, document "not available.")

Behavioral Observations: [Developmentally framed observations—engagement, activity level, affect, language, reciprocity, anxiety signs, repetitive behaviors as relevant; note who was present] (Document only what was observed; do not auto-populate normal findings.)

Assessment

[Problem list in order of clinical priority; for each problem include current status as improving / stable / worsening / unclear, attributed to data source, with 1–2 key supporting facts] (Include diagnostic uncertainty only if it affects management.)

Plan

(Organize by problem, matching Assessment order. For each problem, include applicable elements below.)

• Medication changes: [what will change, target symptoms, monitoring plan, instructions if adverse effects occur]
• School recommendations: [functional needs and supports recommended; note if documentation will be sent]
• Therapy/behavioral interventions: [continue / adjust / refer; home strategies if taught]
• Coordination tasks: [what, who responsible, by when]
• Follow-up: [timing, data needed by next visit, when to call sooner]

(Omit bullets not applicable. Do not copy-forward interval-dependent content.)