Well-Child Visit Note (Infant/Toddler)

Date: [Date]

Patient Name: [Patient name]

Age: [Age in months or years; include corrected gestational age if premature]

Historian: [Relationship to child; note if limited history or interpreter used]

History

[Visit reason and caregiver concerns] (State routine health supervision; summarize any caregiver concerns with brief context and relevant interval events such as illnesses, injuries, or care changes.)

[Interval history] (Address nutrition/feeding including type, frequency, and supplements such as vitamin D or iron when relevant; sleep duration, environment, and safe sleep practices for infants; elimination patterns; developmental observations across motor, language, and social-emotional domains with explicit note of any loss of previously acquired skills; relevant safety practices such as car seat and sleep position; exposures of concern. Update medical, family, or social history only if changed since last visit. Omit formal review of systems unless a specific concern prompts it.)

Objective

Growth: [Weight, length/height, head circumference if age-appropriate, with percentiles; weight-for-length under 2 years or BMI at 2+ years; trajectory note]. (Use WHO growth standards under age 2 and CDC growth charts at age 2 and older. If a measurement is expected but not obtained, document "Not obtained [reason]".)

Exam: [Pertinent findings by system — general appearance/interaction, head/fontanelles, eyes including red reflex in infancy, ears/nose/throat, cardiovascular with femoral pulses in early infancy, respiratory, abdomen, genitourinary, hips/musculoskeletal, skin, neurologic tone/symmetry, developmental skills observed]. (Document pertinent positives and negatives. Omit elements not applicable to the child's age.)

Assessment

• [Preventive well-child visit, age]: [Summary of growth and developmental status]
• [Secondary diagnosis if applicable]: [Brief assessment]

Plan

Screenings: [Standardized tools administered today — developmental screen, autism screen, maternal depression screen, lead test, hemoglobin, fluoride varnish, vision/hearing as age-appropriate — with tool name, result, interpretation, and action taken]. (If a due screening was not completed, document "Not obtained [reason]" and follow-up plan.)

Immunizations:

• [Vaccines administered]: [Vaccine name, manufacturer, lot number, VIS edition date provided, route/site, administrator]. (Repeat for each vaccine.)
• [Immunization history source]: [registry / records / parent report]
• [Vaccines declined/deferred, if any]: [Who declined, counseling provided, follow-up plan]

Guidance: [Age-appropriate anticipatory guidance topics addressed, such as nutrition, safe sleep, car seat safety, developmental stimulation, oral health, injury prevention, media limits]

Follow-up: [Next routine well-child visit interval; earlier return if indicated for weight check, screening follow-up, or specific concerns]

Problem-Oriented Care

(Include this section only if a separately identifiable problem-oriented evaluation was performed beyond routine preventive care.)

Focused HPI: [Problem-specific history]

Focused Exam: [Pertinent findings for this issue]

Assessment: [Diagnosis/clinical impression]

Treatment Plan: [Medications, tests, counseling, referrals, follow-up for this problem]