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Example of New Patient Well-Child Visit 0-12 months (Mock Record B1)

Name: Jones, Joe ID: 0001 Sex: Male Age: 6 months, 5 days

Date of Service: 01/02/2012

SUBJECTIVE:

This six month old male infant presents for well-child examination. Infant lives with father, mother and
brother.

Interim problems since last visit NONE

Review of Systems

Constitutional: Negative Eyes: Negative ENT: Negative

Cardiovascular: Negative Respiratory: Negative Gastrointestinal: Negative

Genitourinary: Negative Musculoskeletal: Negative Integumentary: Negative

Neurological: Negative Hematologic: Negative Allergies: Negative

Chronic Problems: none

Nutrition: Taking 6-8 oz of baby formula every 4 hours while awake. Solid foods eaten in form of baby
cereal, fruit and vegetables (20 36oz daily)

Developmental milestones: Razzing yes; Reaches for objects yes; Pulls to sit without head lag Yes,
not so with lag; Smiles spontaneously yes; Orients to bell yes; Babbling yes

OBJECTIVE:

Height: 27.1 inches Weight: 16.67 pounds. Well appearing infant in no distress

Congenital anomalies: none

Head: normocephalic, atraumatic

Eyes: visual acuity intact, conjunctiva clear sclera non-icteric EOM intact, Red light reflex bilaterally,
PERRL, fundi have normal optic discs and vessels, no exudates or hemorrhages, no evidence of
strabismus

Ears: EACs clear, TMs translucent and mobile, ossicles normal appearance, hearing intact

Nose: nares patent

Mouth: Mucous membranes moist, no mucosal lesions


Neck: good tone, no adenopathy or masses

Heart: no cardiomegaly or thrills, regular rate and rhythm, no murmur or gallop, radio-femoral pulses
present and palpable simultaneously

Lungs: Clear to auscultation and percussion

Abdomen: Bowel sounds normal, no tenderness, organomegaly, masses, or hernia

Genitalia: circumcised penis, urethral meatus patent, no hypospadias, testes descended, no hernias, no
scrotal masses.

Extremities: no deformities, full range of motion

Skin: good turgor, no rash or prominent lesions

PLAN:

Due for 6 month shots: IPV, DTap, Hep B, PCV, HiB. Follow up at 12 months of age.

Parent Counseling Nutrition: Stressed importance of intake of iron-rich foods, avoidance of sweets.
Continue breast feeding/formula 16-20oz per day. Injury prevention: Discussed infant safety seat, smoke
detector, hot water heater temperature, electric outlet covers, stairway gates, window guards, storage
of drugs and toxic chemicals, poison control telephone number.

Electronically Signed by:

Julie Beesee, MD 01/02/2012 12:35PM

Codes:

E/M 99381 IMMUNIZATIONS 90645, 90645, 90460, 90670, 90713, 90700, 90461 x 4, 90744

ICD- 9 V20.2, V03.81, V03.82, V04.0, V06.1, V05.3


Example of Established Patient Well-Child Visit Late Childhood 5-11 years (Mock Record B-2)

Name: Jones, Joey ID: 0002 Sex: Male Age: 11 years, 1month

Date of Service: 01/02/2012

SUBJECTIVE:

This eleven year old male presents for well-child examination.

Interim problems since last visit Patients blood sugars around 100, URI symptoms have improved,
Patient exercises often.

Review of Systems

Constitutional: Negative Eyes: Negative ENT: Negative

Cardiovascular: Negative Respiratory: Negative Gastrointestinal: Negative

Genitourinary: Negative Musculoskeletal: Negative Integumentary: Negative

Neurological: Negative Hematologic: Negative Allergies: Negative

Current Medications:

Rx: Levemir 32units at bedtime; Rx: NOVOLOG after meals

Social History:

Occupation student; Education in 6th grade; Nutrition eats healthy; Exercise wrestling and
basketball; Smoking no smoking or use of recreational drugs by any adults in/around the house

Nutrition:

Milk: 2% milk 16 oz/day; Diet habits: emphasizes fruits, vegetables, whole grains, lean meats, poultry,
fish, beans, eggs and nuts.

School performance: A student at appropriate grade level for age.

OBJECTIVE:

Height percentile: 71.78 Weight percentile: 95.47. Well appearing, well-nourished in no distress.
Oriented, normal mood and effect.

Congenital anomalies: none

Head: normocephalic, atraumatic


Eyes: conjunctiva clear, sclera non-icteric, EOM intact, PERRL,

Ears: EACs clear, TMs translucent and mobile, ossicles normal appearance, hearing intact

Mouth: Mucous membranes moist, no mucosal lesions

Neck: good tone, no adenopathy or masses, thyroid non-enlarged and non-tender

Heart: regular rate and rhythm, no murmur or gallop

Lungs: Clear to auscultation and percussion

Abdomen: Bowel sounds normal, no tenderness, organomegaly, masses, or hernia

Genitalia: penis w/o lesions, no inguinal hernias, tanner stage Extremities: no deformities, full range of
motion

Skin: good turgor, no rash or prominent lesions

Extremities: no amputations or deformities, cyanosis, edema or varicosities, peripheral pulses intact.

ASSESSMENT:

Medical Exam: V20.2

OV PS Ext Pt Age 5-11: 99393

DIABETES UNCOM TYPE 1: 250.01

PLAN: Schedule to see Endocrinologist for follow up on diabetes. Discussed diet and exercise with
patient and child and also discussed pubertal changes and sex education. Follow-up in 4 months.

Electronically Signed by:

Julie Beesee, MD 01/02/2012 9:3AM

Codes:

E/M 99393 ICD- 9 V20.2, 250.01