Preventive Visit Note (Student)

Date/Time: [Date and time of encounter]

Patient Name: [Full name as in chart]

Date of Birth: [DOB]

Visit Type: [Well-child visit / Annual preventive exam / Adolescent wellness visit / Pre-participation physical / Other preventive visit] (Explicitly state the preventive visit type to avoid billing confusion.)

Setting: [In-person clinic / Telehealth / School-based clinic / Other]

Student Author: [Name, role/title]

Supervising Clinician: [Name, credentials]

Historian: [Patient / Parent-guardian / Interpreter used (language)] (Specify all applicable.)

Reason for Visit

[Reason for preventive care visit and patient-stated priorities or goals] (1–2 sentences. A direct quote is acceptable. If additional concerns require diagnostic workup, note briefly and indicate they will be addressed in a separate problem-oriented addendum.)

Interval History

[Time since last preventive visit and interval health summary including new diagnoses, hospitalizations, surgeries, medication changes, and overall health status]

PMH/FH Updates: [Relevant changes affecting preventive risk] (Include only new or changed items impacting risk.)

Medications: [Current medications and supplements with adherence concerns] (Focus on changes and concerns.)

Health Behaviors: [Tobacco/nicotine, alcohol, substances, nutrition, physical activity, sleep, sexual/reproductive health as age-appropriate] (Document succinctly; focus on risks and changes.)

Safety: [Age/risk-appropriate safety topics reviewed]

Confidential Time: [Yes / No / N/A] (Include only for adolescents.)

Screening and Immunization Status

Screenings: [Age/sex/risk-appropriate screenings with status: due / completed / deferred / declined] (Include dates and source. If declined, document counseling provided and patient-stated reason.)

Immunizations: [Vaccine record status and source: registry / EHR / patient-provided] (List vaccines due or overdue. Document as "unknown/pending verification" if records incomplete. For any vaccine declined, document counseling and stated reason.)

Objective

Vital Signs: [Relevant vitals with interpretation] (Include growth percentiles and trajectory for pediatric patients.)

Physical Examination: [Pertinent positives and negatives by system examined] (Include only systems actually examined and appropriate to patient age. Document chaperone presence for sensitive exams per policy. If exam was limited, state what and why.)

Point-of-Care Testing: [POC tests performed and results] (Omit if none.)

Data Reviewed: [Labs, imaging, screening tool scores with source and date] (Omit if none.)

Assessment

[Summary of preventive care status] (2–4 sentences highlighting key risk factors, care gaps addressed vs deferred, abnormal findings requiring follow-up, and stable chronic conditions if reviewed. If any problem required substantial evaluation, indicate it is documented in a separate problem-oriented addendum.)

Plan

Screening and Orders: [Orders placed, referrals made, shared decision-making discussions with patient preferences]

Immunizations Administered Today:

• [Vaccine name; date; dose; route; site; manufacturer; lot number; VIS provided; administrator name/title; immediate reaction: none / describe]

(Repeat for each vaccine. Required elements per federal law.)

Vaccines Deferred/Declined: [Vaccine(s), reason, counseling documented, follow-up plan] (Omit if none.)

Counseling and Anticipatory Guidance: [Topics actually discussed, tailored to age and risk, with patient response or goals if relevant]

Follow-Up: [Next preventive visit interval, how pending results will be communicated, timeline for abnormal screen follow-up]

Separately Identifiable Problem-Oriented E/M

(Include only if significant problem-oriented evaluation was performed beyond preventive care. Each problem should stand alone and not duplicate preventive service documentation.)

[Problem]

S: [Focused symptom history]

O: [Focused exam and pertinent data]

A: [Diagnosis or differential]

P: [Management, orders, follow-up]

(Repeat for additional problems as needed.)

Attestation

Student Attestation: I attest that this note reflects my history, examination findings, and assessment/plan for this preventive visit. [Student name, role, date/time]

Supervising Clinician Attestation: [Verification of student documentation, clinician's participation in history/exam/MDM, and any amendments or corrections. Signature, credentials, date/time per local policy.]