Well-Child Visit Note (Child/Adolescent)

Date: [date]

Patient: [name, DOB, age]

Provider: [provider name, credentials]

Visit Type: Well-Child Visit / Preventive Health Supervision

Reason for Visit: [purpose of visit and any specific concerns or forms needed]

Interval History

[Brief narrative summary of domains assessed] (Include only what was actually addressed: interim illnesses/injuries/hospitalizations; medications and allergies reviewed; nutrition, activity, and sleep; school and peer functioning; developmental or behavioral observations; dental care; relevant psychosocial domains. For adolescents, note if private time was offered and confidentiality limits discussed. Omit domains not assessed.)

Screenings

(Document only screenings performed or considered at this visit. For positive mental health or safety screens, include safety assessment performed, guardian involvement plan, referrals made, crisis resources provided, and follow-up timeframe.)

• [Screening tool]: [score/result] ([interpretation]); [action taken]
• (Add additional screenings as applicable; if indicated but not done, note reason)

Objective

Growth: [height, weight, BMI with percentiles; BP with percentile if elevated]

Exam: [pertinent findings by system] (Include Tanner stage only if pubertal exam performed.)

POC/Labs: [point-of-care results and/or labs ordered] (Omit if none.)

Assessment

[Brief overall assessment] (Include: growth trajectory and BMI category; development and school functioning; mental health screening summary; immunization status; identified risks or concerns. List additional problems addressed if applicable.)

Plan

Immunizations: [vaccines administered with route/site; VIS provided; vaccines declined/deferred with reason and follow-up plan]

Anticipatory Guidance: [topics covered, tailored to age and concerns] (Document only topics actually discussed—e.g., nutrition, sleep, safety, screen time, substance prevention, sexual health.)

Referrals/Orders: [screenings, specialty referrals, labs ordered] (Omit if none.)

Follow-up: [next preventive visit interval; earlier follow-up if indicated]

Problem-Oriented Care

(Include only if a separately billable problem beyond routine preventive care was addressed. Supports billing with modifier -25.)

[Problem]: [diagnosis/clinical impression]

[Assessment specific to this problem]

• [Plan elements: medications, tests, counseling, referrals, follow-up as applicable]