Well-Child Visit Note (Bright Futures)

Date/Time: [date and time]
Patient: [full name, DOB, age in months if <24 months, sex]
Accompanying Adult: [name and relationship]
Historian: [source of history; reliability; interpreter used and language if applicable]

History

(Tailor all content to the patient's age and Bright Futures health supervision domains. Keep to 2–3 concise paragraphs.)

[Visit purpose and concerns] (Begin with routine health supervision and any specific concerns or requests voiced by parent/caregiver and/or patient.)

[Interval history by age] (Brief, age-tailored summary of: nutrition/feeding; sleep; elimination patterns; developmental milestones and behavior; school/daycare performance if applicable; physical activity and screen/media use. Note strengths and protective factors when present. If a clinically expected domain was not assessed, state "not reviewed.")

[Social and family context] (Household composition, caregiving arrangements, social determinants of health concerns or supports identified. For adolescents seen privately, note that confidential history was obtained; document sensitive content per organizational confidentiality policy.)

Screenings

(List standardized screening tools administered this visit. Omit section if no screenings were indicated or performed.)

• [Screening tool name]: [score/result], [positive / negative / at-risk], [action taken]. (Repeat per tool. If a recommended age-based screen was not performed, document reason.)

Objective

Vitals/Growth: Temp [value]; HR [value]; RR [value]; BP [value] (if age ≥3 or indicated); Pain [score]. Weight [value] ([percentile]); [Length / Height] [value] ([percentile]); HC [value] ([percentile]) (if <3 years); BMI [value] ([percentile]) (if ≥2 years). [One-line growth interpretation.]

Exam: [Pertinent findings organized by system, tailored to age and concerns. Include relevant negatives linked to reported issues. Note chaperone presence or declination for sensitive exams.]

Sensory Screening: Vision: [method], [pass / refer]. Hearing: [method], [pass / refer]. (Include only if performed.)

POC/Labs: [test name and result with brief interpretation] (Include only completed results; pending orders go in Plan. Omit if none.)

Assessment

Visit classification: Routine health supervision, [age], [with / without] abnormal findings.

• Growth/nutrition: [summary; BMI category if applicable]
• Development/behavior: [age-appropriate / concern identified]
• Immunization status: [up-to-date / delayed / specific gaps]
• Screening outcomes: [results requiring follow-up] (Include only if applicable.)
• Additional problem(s): [problem-oriented assessments] (Include only if applicable.)

Plan

• [Problem]: [brief assessment and action items]. (Repeat for each problem addressed.)

Anticipatory Guidance: [specific topics discussed, tailored to age and family context] (List topics actually discussed; avoid generic statements like "anticipatory guidance given.")

Immunizations:

• Administered: [vaccine name], [dose], [route], [site], [manufacturer], [lot number], [VIS edition date given], [administrator]. (Repeat per vaccine.)
• Not given: [vaccine name] — [reason: contraindication / illness / declined / supply issue / deferred]. [Counseling provided and plan to revisit.] (Include only if applicable.)

Orders/Referrals: [labs, imaging, referrals with indication] (Include only if applicable.)

Follow-up: [next routine well visit interval]. [Earlier follow-up if indicated for specific concerns.] [Return precautions if applicable.]

Clinician Signature: [name, credentials]