Pediatric Obesity/Insulin Resistance Visit Note

Encounter Header

Encounter type: [new / follow-up] | Date: [Date] | Modality: [in-person / telehealth]
Provider(s): [Name(s), credentials]
Historian/source: [patient / parent-guardian / other] (Specify relationship; note interpreter language if used.)
Referring clinician: [Name, specialty] (New consults only.)
Referral question: [Stated question or "not specified"]
Adolescent confidential time: [occurred / not applicable] (Include only for adolescents.)

Chief Concern

[Reason for visit and today's agenda in 1–3 sentences] (May include a brief patient/family quote. Keep concise and goal-oriented.)

History

Summary: [Brief narrative of clinical story integrating weight and growth trajectory context] (Summarize when weight concerns began, evolution, and key prior evaluations or treatments. Use people-first, weight-neutral language.)

Growth Pattern: [Onset/tempo of weight gain; trends in height, weight, BMI percentiles; pubertal context] (State explicitly whether pattern is consistent with exogenous obesity versus concerning for secondary/endocrine etiology—screen for declining height velocity, Cushingoid features, hypothyroid symptoms, early-onset severe obesity with hyperphagia or developmental features. Note if prior growth data unavailable.)

Lifestyle: [Nutrition patterns including meals, beverages, portions, food environment/access; physical activity minutes/day with barriers; sleep duration/quality with OSA symptoms such as snoring, apneas, daytime sleepiness] (Document salient facilitators and barriers.)

Metabolic/Comorbidity Symptoms: [Pertinent positives and negatives for dysglycemia, NAFLD, OSA, PCOS if applicable, orthopedic pain suggesting SCFE, psychosocial concerns]

Background: [Current/prior weight-affecting medications; prior anti-obesity medication trials and response; family history of T2D, dyslipidemia, premature CVD, NAFLD, PCOS, severe obesity; relevant social history including household, food access, activity environment] (For follow-ups, update only changed items.)

Objective

Vitals/Growth: Height [value], Weight [value], BMI [value], BMI percentile [value], BMI category [underweight / healthy weight / overweight / obesity class I / class II / class III], % of 95th percentile [value]. Blood pressure [SBP/DBP] — [normal / elevated / stage 1 / stage 2]. Historical trajectory: [2–3 prior timepoints with dates if available]. Height velocity: [cm/yr if calculable].

Exam: [Focused findings relevant to obesity/metabolic evaluation including acanthosis nigricans location and severity, striae, hirsutism/acne if present, thyroid, hepatomegaly assessment, gait/hip ROM if SCFE concern, Tanner staging only if changes differential or management]

Data Reviewed:

• Glycemia: [Test, result, date] — [normoglycemia / insulin resistance phenotype / prediabetes / diabetes]
• Liver: ALT [value, date] vs pediatric ULN — [interpretation]
• Lipids: [Values with date] — [one-line interpretation]
• Other data: [Relevant labs, imaging, or external records reviewed with key findings] (Include endocrine testing if obtained.)

Assessment

(Use people-first, weight-neutral language with explicit diagnoses and severity.)

• Weight status: [Obesity class I / class II / class III / overweight] (BMI [value], [percentile], [% of 95th])
• Insulin resistance/glycemia: [Insulin resistance phenotype / prediabetes / diabetes] supported by [test and date]
• Comorbidities: [Confirmed or suspected conditions with certainty language: NAFLD risk, dyslipidemia, OSA, PCOS, orthopedic, psychosocial as applicable]
• Secondary-cause screen: [Low concern for endocrine etiology given preserved linear growth / Evaluation indicated due to specific features] (State explicit conclusion.)

Plan

Lifestyle Treatment: [Counseling topics addressed and behavioral approach used]. SMART goals: [1–3 patient-chosen goals with confidence rating and barriers identified]. [Intensive lifestyle program referral if indicated.]

Screening and Monitoring: [Current status and next-due timing for dysglycemia, dyslipidemia, NAFLD/ALT, blood pressure, OSA, PCOS if relevant]. Orders placed: [Tests ordered with rationale]. Endocrine testing: [Indicated with growth-pattern rationale / Not indicated—state why].

Pharmacotherapy: (Include when considering, starting, or continuing anti-obesity medication.)
Eligibility: [Age, BMI severity, comorbidities, prior lifestyle treatment]. Contraindication screening: [Pregnancy risk assessment with test result if applicable; relevant history for medication class]. Shared decision-making: [Options discussed, preferences, risks/benefits reviewed]. Plan: [Agent, dose, titration, monitoring parameters, side effect counseling]. (If indicated but deferred, document reason and alternative plan.)

Surgery Consideration: (Include for severe obesity with significant comorbidities.)
[Eligibility and readiness factors]; [Referral placed / deferred with reason].

Referrals: [Dietitian, behavioral health, sleep medicine, hepatology, orthopedics, others as indicated with reason]

Follow-Up: [Interval]; [What will be reviewed]; [Lab timing and location].

Time: [Total clinician time in minutes] (Include if billing by time.)