Tài liệu Practice Guidelines 2013 Pediatric Well Child Care Flow Sheets ppt

Health care benefit programs issued or administered by Capital BlueCross and/or its subsidiaries, Capital Advantage Insurance Company ® , Capital Advantage Assurance Company ® and Keystone Health Plan ® Central. Independent licensees of the BlueCross BlueShield Association. Communications issued by Capital BlueCross in its capacity as administrator of programs and provider relations for all companies. Practice Guidelines 2013 Pediatric Well Child Care Flow Sheets PHYSICIAN GUIDELINES FOR PREVENTIVE SERVICES Capital BlueCross’ Physician Guidelines for Preventive Services should serve as a useful component of your delivery of preventive services. We urge you to refer to them frequently and aim for the highest compliance possible. Additional suggestions follow:  Make preventive services one of your practice’s highest priorities.  Consider every visit as an opportunity to promote wellness services.  If time and resources are especially scarce, try devoting attention to at least a few key areas on a seasonal basis.  Post a copy of the Guidelines in each consultation/exam room.  Reinforce our efforts to educate Members about the importance of health maintenance interventions.  Use office reminder systems, including wall posters and chart alerts.  Involve non-physician staff in the process, including the delegation of specific responsibilities. The Guidelines include: Adult Health Maintenance Guidelines (Commercial) Adult Health Maintenance Guidelines (SeniorBlue and SeniorBlue PPO) Child Health Maintenance Guidelines Pediatric Well Child Care Flow Sheets PEDIATRIC WELL CHILD CARE PATIENT’S NAME: ______________________________ 2/94; REV.: 1/97; 3/98, 3/99, 5/02, 4/04, 6/05, 3/08, 4/09, 3/10, 4/12 T:\QM\TRANSFER\FORMS\PED CHART REVISED 6-05.DOC LAST PRINTED 5/30/2012 2:03:00 PM Health care benefit programs issued or administered by Capital BlueCross and/or its subsidiaries, Capital Advantage Insurance Company ® ® and Keystone Health Plan ® ® Central. Independent licensees of the Blue Cross and Blue Shield Association. Communications issued by Capital BlueCross in its capacity as administrator of programs and provider relations for all companies. DEVELOPMENTAL TASKS PRESENT NORMAL ABNORMAL (DESCRIBE BELOW) NUTRITION ANTICIPATORY GUIDANCE AND SAFETY 2-4 Weeks Equal Movements Length Wt. HC Breast Car restraints Palmar grasp General Appearance Formula Crib safety Date of Visit Raises head when prone Skin Fem. Art. Sleep position Regards face Head Abdomen Babysitters Follows to midline Responds to sound Fontanelle Eyes Umbilic Genitalia Pet control Secondary tobacco smoke Red Reflex Testes Tap water not to exceed 120F Follow-up on abnormal ENT Extrem for bathing Newborn Screens Lungs Hips Smoke detectors Heart Neuro Vitamins (breast-fed babies) Coughs/colds Urine Comments: Abnormalities: Stools Return_____________ Provider Initials______ DEVELOPMENTAL TASKS PRESENT NORMAL ABNORMAL (DESCRIBE BELOW) NUTRITION ANTICIPATORY GUIDANCE AND SAFETY 1 Month Equal Movements Length Wt. HC Breast Car restraints Palmar grasp General Appearance Formula Crib safety Date of Visit Raises head when prone Skin Fem. Art. Sleep position Regards face Head Abdomen Babysitters Follows to midline Responds to sound Fontanelle Eyes Umbilic Genitalia Pet control Secondary tobacco smoke Red Reflex Testes Tap water not to exceed 120F ENT Extrem for bathing Lungs Hips Smoke detectors Heart Neuro Coughs/colds Urine Immunizations: Comments: Abnormalities: Stools Return_____________ Provider Initials______ DEVELOPMENTAL TASKS PRESENT NORMAL ABNORMAL (DESCRIBE BELOW) NUTRITION ANTICIPATORY GUIDANCE AND SAFETY 2 Months Lifts head temp. erect Length Wt. HC Breast Sleep patterns when held upright General Appearance Formula Daycare / babysitters Date of Visit Regards face in direct line Skin Fem Art. Sleep position of vision Grasps rattle placed in hand Head Fontanelle Eyes Abdomen Genitalia Testes Fall prevention Coughs/colds Social smile Coos ENT Lungs Extrem Hips Responds to sound Heart Neuro Immunizations: Urine Comments: Abnormalities: Stools Return_____________ Provider Initials______ PEDIATRIC WELL CHILD CARE PATIENT’S NAME: ______________________________ 2/94; REV.: 1/97; 3/98, 3/99, 5/02, 4/04, 6/05, 3/08, 4/09, 3/10, 4/12 T:\QM\TRANSFER\FORMS\PED CHART REVISED 6-05.DOC LAST PRINTED 5/30/2012 2:03:00 PM Health care benefit programs issued or administered by Capital BlueCross and/or its subsidiaries, Capital Advantage Insurance Company ® ® and Keystone Health Plan ® ® Central. Independent licensees of the Blue Cross and Blue Shield Association. Communications issued by Capital BlueCross in its capacity as administrator of programs and provider relations for all companies. DEVELOPMENTAL TASKS PRESENT NORMAL ABNORMAL (DESCRIBE BELOW) NUTRITION ANTICIPATORY GUIDANCE AND SAFETY 4 Months Holds head high Length Wt. HC Breast Sleep position Raises body on hands General Appearance Formula Reinforce falls prevention Date of Visit when prone Skin Heart Avoid small objects Rolls prone to supine Plays with hands Follows parent with eyes Eyes Head Fontanelle Fem Art. Abdomen Genitalia Coughs/colds Smiles, coos, laughs, squeals, gurgles ENT Lungs Extrem Hips Cereal Neuro Immunizations: Comments: Abnormalities: Stools Return_____________ Provider Initials______ DEVELOPMENTAL TASKS PRESENT NORMAL ABNORMAL (DESCRIBE BELOW) NUTRITION ANTICIPATORY GUIDANCE AND SAFETY 6 Months Sits with support Length Wt. HC Breast Passes hand to hand General Appearance Formula Check home for hazards Date of Visit Rolls over Head Heart hot liquids, electrical outlets, Reaches for toys Bears weight Raking hand pattern Babbles, laughs Fontanelle Skin EOM ENT Fem Art. Abdomen Genitalia Extrem poisons, medicines, dangling cords or table covers Provide Poison Control phone # Turns to voice Eyes Teeth Hips Neuro Puréed foods (including Sleep position Sun exposure Lungs iron sources) Crib safety Fluoride Car restraints Coughs/colds Comments: Abnormalities: Immunizations: Return_____________ Provider Initials______ DEVELOPMENTAL TASKS PRESENT NORMAL ABNORMAL (DESCRIBE BELOW) NUTRITION ANTICIPATORY GUIDANCE AND SAFETY 9 Months Sits well Length Wt. HC Breast Home safety Crawls, creeps General Appearance Formula Avoid popcorn, nuts, raw carrot Date of Visit Pulls to stand Head Heart Table Food or celery sticks, raw apple, raisins Assisted walking Inferior pincer grasps - pokes Fontanelle Skin ENT Abdomen Genitalia Neuro or tiny pieces of toys Family/social dynamics Sun exposure Bangs two toys together Pat-a-cake Peek-a-boo Imitates speech sounds “Dada” Mama” Eyes Teeth Lungs Extrem Hips Self-feeding Toast Teething bisc. Wean to cup Fluoride Tooth care Car restraints Coughs/colds Immunizations: Comments: Abnormalities: Stools Return_____________ Provider Initials______ PEDIATRIC WELL CHILD CARE PATIENT’S NAME: ______________________________ 2/94; REV.: 1/97; 3/98, 3/99, 5/02, 4/04, 6/05, 3/08, 4/09, 3/10, 4/12 T:\QM\TRANSFER\FORMS\PED CHART REVISED 6-05.DOC LAST PRINTED 5/30/2012 2:03:00 PM Health care benefit programs issued or administered by Capital BlueCross and/or its subsidiaries, Capital Advantage Insurance Company ® ® and Keystone Health Plan ® ® Central. Independent licensees of the Blue Cross and Blue Shield Association. Communications issued by Capital BlueCross in its capacity as administrator of programs and provider relations for all companies. DEVELOPMENTAL TASKS PRESENT NORMAL ABNORMAL (DESCRIBE BELOW) NUTRITION ANTICIPATORY GUIDANCE AND SAFETY 12 Months Pulls to stand Length Wt. HC Breast SAFETY poison-proofing; Walks w/support or few General Appearance Milk stair safety, water safety, auto seat Date of Visit steps alone Head Heart (whole milk) restraints; fences and gates Precise pincer grasp Points Has 1-3 new words plus Fontanelle Skin ENT Abdomen Genitalia Extrem Table foods Continue weaning Tooth care Sun exposure Coughs/colds “Dada” “Mama” Looks for dropped or hidden objects Eyes Teeth Lungs Hips Neuro to cup MVI Immunizations: Comments: Abnormalities: Fluoride Return_____________ Provider Initials______ DEVELOPMENTAL TASKS PRESENT NORMAL ABNORMAL (DESCRIBE BELOW) NUTRITION ANTICIPATORY GUIDANCE AND SAFETY 15 Months Walks alone Length Wt. HC Milk REEMPHASIZE: Crawls up stairs Puts raisin in bottle General Appearance Skin Fem Art. Toothcare No bottle in Home/environment safety Socialization Date of Visit Points to 1-2 body parts Eyes Abdomen bed Tantrums/behavior Gestures Understands simple commands Head Fontanelle ENT Genitalia Testes Extrem Finger foods Fluoride Sun exposure Coughs/colds Uses cup Teeth Lungs Gait Neuro MVI Heart Immunizations: Comments: Abnormalities: Return_____________ Provider Initials______ DEVELOPMENTAL TASKS PRESENT NORMAL ABNORMAL (DESCRIBE BELOW) NUTRITION ANTICIPATORY GUIDANCE AND SAFETY 18 Months Walks up stairs with help Length Wt. HC Mealtime not STRESS FIRMLY: Sits in a chair General Appearance to be a battle Stairs & window safety Date of Visit 3-4 Cube tower Uses spoon Head Fontanelle Abdomen Genitalia Discourage snacks Avoid playing in street/driveway Coughs/colds Imitates a crayon stroke 4-10 words May tell 2 or more wants Skin Eyes ENT Testes Extrem Gait Toothcare Fluoride Don’t leave alone in car or home Guard against falls, electrical injuries, drowning Knows body parts Autism screening Teeth Lungs Neuro MVI Sleep patterns & night fears Toothbrushing Heart Sun exposure Comments: Abnormalities: Immunizations: Return_____________ Provider Initials______ PEDIATRIC WELL CHILD CARE PATIENT’S NAME: ______________________________ 2/94; REV.: 1/97; 3/98, 3/99, 5/02, 4/04, 6/05, 3/08, 4/09, 3/10, 4/12 T:\QM\TRANSFER\FORMS\PED CHART REVISED 6-05.DOC LAST PRINTED 5/30/2012 2:03:00 PM Health care benefit programs issued or administered by Capital BlueCross and/or its subsidiaries, Capital Advantage Insurance Company ® ® and Keystone Health Plan ® ® Central. Independent licensees of the Blue Cross and Blue Shield Association. Communications issued by Capital BlueCross in its capacity as administrator of programs and provider relations for all companies. DEVELOPMENTAL TASKS PRESENT NORMAL ABNORMAL (DESCRIBE BELOW) NUTRITION ANTICIPATORY GUIDANCE AND SAFETY 24 Months Walks up steps Ht. Wt. HC Avoid fights STRESS DANGERS: Burns, falls Jumps in place Sits in a chair General BMI Skin Lungs Over eating No snacks from windows, cabinets, furniture; eat and drink when sitting; poison Date of Visit 5-6 Cube tower Eyes Heart Fluoride danger; avoid machinery, plastic Makes horizontal or circular strokes 50+ Words Knows name Head ENT Hearing Vision Abdomen Genitalia Extrem Neuro MVI bags Read to child Toilet training Sun exposure “What’s that?” Parents understand child’s Teeth Poison control information Coughs/colds speech Autism screening Immunizations: Comments: Abnormalities: Return_____________ Provider Initials______ DEVELOPMENTAL TASKS PRESENT NORMAL ABNORMAL (DESCRIBE BELOW) NUTRITION ANTICIPATORY GUIDANCE AND SAFETY 30 Months Walks up steps Ht. Wt. HC Avoid fights STRESS DANGERS: Burns, falls Jumps in place Sits in a chair General BMI Skin Lungs Over eating No snacks from windows, cabinets, furniture; eat and drink when sitting; poison Date of Visit 5-6 Cube tower Eyes Heart Fluoride danger; avoid machinery, plastic Makes horizontal or circular strokes 50+ Words Knows name Head ENT Hearing Vision Abdomen Genitalia Extrem Neuro MVI bags Read to child Toilet training Sun exposure “What’s that?” Parents understand child’s Teeth Poison control information Coughs/colds speech Able to pedal Immunizations: Comments: Abnormalities: Return_____________ Provider Initials______ DEVELOPMENTAL TASKS PRESENT NORMAL ABNORMAL (DESCRIBE BELOW) NUTRITION ANTICIPATORY GUIDANCE AND SAFETY 3 Years Kicks ball Ht. Wt. BP Avoid junk Car seat Pedals tricycle Opens door General BMI Skin Teeth drinks & food Feeds self Knives out of reach Stay out of streets Date of Visit 9 Cube tower Head Lungs entirely Water safety Copies circle Does some dressing Feeds self Eyes ENT EOM Heart Abdomen Back Read to child Speech or language evaluation Sun exposure Knows full name, age, sex Counts to three Comprehends “tired, “cold,” “hungry” Vision test Genitalia Extrem Neuro Dental care & referral Fluoride Coughs/colds Immunizations: MVI Comments: Abnormalities: Return_____________ Provider Initials______ PEDIATRIC WELL CHILD CARE PATIENT’S NAME: ______________________________ 2/94; REV.: 1/97; 3/98, 3/99, 5/02, 4/04, 6/05, 3/08, 4/09, 3/10, 4/12 T:\QM\TRANSFER\FORMS\PED CHART REVISED 6-05.DOC LAST PRINTED 5/30/2012 2:03:00 PM Health care benefit programs issued or administered by Capital BlueCross and/or its subsidiaries, Capital Advantage Insurance Company ® ® and Keystone Health Plan ® ® Central. Independent licensees of the Blue Cross and Blue Shield Association. Communications issued by Capital BlueCross in its capacity as administrator of programs and provider relations for all companies. DEVELOPMENTAL TASKS PRESENT NORMAL ABNORMAL (DESCRIBE BELOW) NUTRITION ANTICIPATORY GUIDANCE AND SAFETY 4 Years Hops, jumps forward Ht. Wt. BP Family talk REEMPHASIZE: Water safety; Climbs ladder Can cut & paste General BMI Skin Teeth mealtimes Offer small street crossing and/or play; booster seat, and/or appropriate Date of Visit Knows 3 or 4 colors Head Lungs portions seat belt placement; avoid Dresses & undresses w/supervision Counts to 10 Gender ID Eyes EOM ENT Vision test Heart Abdomen Back Neuro Seconds available strangers; home fire safety; sleep in own bed Sun exposure Marble & card games; bed time Draws person - 3 parts Copies cross, circle & maybe square Genitalia Extrem Dental care Fluoride ritual; nursery school, daycare, babysitting Car booster seat MVI Bike helmet Coughs/colds Immunizations: Comments: Abnormalities: Return_____________ Provider Initials______ DEVELOPMENTAL TASKS PRESENT NORMAL ABNORMAL (DESCRIBE BELOW) NUTRITION ANTICIPATORY GUIDANCE AND SAFETY 5 Years Hops on one foot Ht. Wt. BP Balanced diet Seat belts Dresses & undresses self Can throw and catch a General BMI Skin Teeth Street sense School experiences/readiness Date of Visit bean bag Head Lungs Separates from parents Gallops, begins skipping, alterntaing feet Prints some letters and numbers Eyes EOM ENT Heart Abdomen Back Neuro Family dynamics Bike helmet Car booster seat Sun exposure Vision test Genitalia Extrem Dental care Fluoride Hearing test MVI Immunizations: Comments: Abnormalities: Return_____________ Provider Initials______ DEVELOPMENTAL TASKS PRESENT NORMAL ABNORMAL (DESCRIBE BELOW) NUTRITION ANTICIPATORY GUIDANCE AND SAFETY 6 Years Rides bicycle Ht. Wt. BP Balanced diet Bike/traffic safety Laces and ties shoes Growing capacity for self- General BMI Skin Teeth Monitor snacks Home environment School environment Date of Visit regulation of behavior Head Lungs Car booster seat Can answer phone, take simple messages School experiences Eyes EOM ENT Heart Abdom Back Sun exposure Firearm safety Exercise Vision test Genit Extrem Dental care Fluoride Hearing test Neuro MVI Immunizations: Comments: Abnormalities: Return_____________ Provider Initials______ PEDIATRIC WELL CHILD CARE PATIENT’S NAME: ______________________________ 2/94; REV.: 1/97; 3/98, 3/99, 5/02, 4/04, 6/05, 3/08, 4/09, 3/10, 4/12 T:\QM\TRANSFER\FORMS\PED CHART REVISED 6-05.DOC LAST PRINTED 5/30/2012 2:03:00 PM Health care benefit programs issued or administered by Capital BlueCross and/or its subsidiaries, Capital Advantage Insurance Company ® ® and Keystone Health Plan ® ® Central. Independent licensees of the Blue Cross and Blue Shield Association. Communications issued by Capital BlueCross in its capacity as administrator of programs and provider relations for all companies. DEVELOPMENTAL TASKS PRESENT NORMAL ABNORMAL (DESCRIBE BELOW) NUTRITION ANTICIPATORY GUIDANCE AND SAFETY 7 Years Rides bicycle Ht. Wt. BP Balanced diet Bike/traffic safety Laces and ties shoes Growing capacity for self- General BMI Skin Teeth Monitor snacks Home environment School environment Date of Visit regulation of behavior Head Lungs Car booster seat Can answer phone, take simple messages School experiences Eyes EOM ENT Heart Abdom Back Sun exposure Firearm safety Exercise Vision test Genit Extrem Dental care Fluoride Hearing test Neuro MVI Immunizations: Comments: Abnormalities: Return_____________ Provider Initials______ DEVELOPMENTAL TASKS PRESENT NORMAL ABNORMAL (DESCRIBE BELOW) NUTRITION ANTICIPATORY GUIDANCE AND SAFETY 8 Years Physical/skills develop Ht. Wt. BP Balanced diet Illicit drugs/alcohol/tobacco Emotional development Intellectual development General BMI Skin Genitalia Monitor snacks Home environment Puberty Date of Visit Social development HEENT Extrem Exercise Community Interests Teeth Nodes Chest Back Neuro Peer pressure Family dynamics Seat belt placement Heart Abdomen Vision test Dental care Fluoride Sun exposure Firearm safety Comments: Abnormalities: MVI Immunizations: Return_____________ Provider Initials______ DEVELOPMENTAL TASKS PRESENT NORMAL ABNORMAL (DESCRIBE BELOW) NUTRITION ANTICIPATORY GUIDANCE AND SAFETY 9 Years Physical/skills develop Ht. Wt. BP Balanced diet Illicit drugs/alcohol/tobacco Emotional development Intellectual development General BMI Skin Genitalia Monitor snacks Home environment Puberty Date of Visit Social development HEENT Extrem Exercise Community Interests Teeth Nodes Chest Back Neuro Peer pressure Family dynamics Seat belt placement Heart Abdomen Vision test Dental care Fluoride Sun exposure Firearm safety Comments: Abnormalities: MVI Immunizations: Return_____________ Provider Initials______ PEDIATRIC WELL CHILD CARE PATIENT’S NAME: ______________________________ 2/94; REV.: 1/97; 3/98, 3/99, 5/02, 4/04, 6/05, 3/08, 4/09, 3/10, 4/12 T:\QM\TRANSFER\FORMS\PED CHART REVISED 6-05.DOC LAST PRINTED 5/30/2012 2:03:00 PM Health care benefit programs issued or administered by Capital BlueCross and/or its subsidiaries, Capital Advantage Insurance Company ® ® and Keystone Health Plan ® ® Central. Independent licensees of the Blue Cross and Blue Shield Association. Communications issued by Capital BlueCross in its capacity as administrator of programs and provider relations for all companies. DEVELOPMENTAL TASKS PRESENT NORMAL ABNORMAL (DESCRIBE BELOW) NUTRITION ANTICIPATORY GUIDANCE AND SAFETY 10 Years Physical/skills develop Ht. Wt. BP Balanced diet Illicit drugs/alcohol/tobacco Emotional development Intellectual development General BMI Skin Genitalia Monitor snacks Home environment Puberty Date of Visit Social development HEENT Extrem Exercise Community Interests Teeth Nodes Chest Back Neuro Peer pressure Family dynamics Seat belt placement Heart Abdomen Vision test Dental care Fluoride Sun exposure Firearm safety Comments: Abnormalities: MVI Immunizations: Return_____________ Provider Initials______ DEVELOPMENTAL TASKS PRESENT NORMAL ABNORMAL (DESCRIBE BELOW) NUTRITION ANTICIPATORY GUIDANCE AND SAFETY 11 Years Physical/skills develop Ht. Wt. BP Balanced diet Illicit drugs/alcohol/tobacco Emotional development Intellectual development General BMI Skin Genitalia Monitor snacks Home environment Puberty Date of Visit Social development HEENT Extrem Exercise Community Interests Teeth Nodes Chest Back Neuro Peer pressure Family dynamics Seat belt placement Heart Abdomen Vision test Dental care Fluoride Sun exposure Firearm safety Comments: Abnormalities: MVI Immunizations: Return_____________ Provider Initials______ DEVELOPMENTAL TASKS PRESENT NORMAL ABNORMAL (DESCRIBE BELOW) NUTRITION ANTICIPATORY GUIDANCE AND SAFETY 12 Years Physical/skills develop Ht. Wt. BP Balanced diet Illicit drugs/alcohol/tobacco Emotional development Intellectual development General BMI Skin Genitalia Monitor snacks Home environment Puberty Date of Visit Social development HEENT Extrem Exercise Community Interests Teeth Nodes Chest Back Neuro Peer pressure Family dynamics Seat belt placement Heart Abdomen Vision test Dental care Fluoride Sun exposure Firearm safety Comments: Abnormalities: MVI Immunizations: Return_____________ Provider Initials______ PEDIATRIC WELL CHILD CARE PATIENT’S NAME: ______________________________ 2/94; REV.: 1/97; 3/98, 3/99, 5/02, 4/04, 6/05, 3/08, 4/09, 3/10, 4/12 T:\QM\TRANSFER\FORMS\PED CHART REVISED 6-05.DOC LAST PRINTED 5/30/2012 2:03:00 PM Health care benefit programs issued or administered by Capital BlueCross and/or its subsidiaries, Capital Advantage Insurance Company ® ® and Keystone Health Plan ® ® Central. Independent licensees of the Blue Cross and Blue Shield Association. Communications issued by Capital BlueCross in its capacity as administrator of programs and provider relations for all companies. DEVELOPMENTAL TASKS PRESENT NORMAL ABNORMAL (DESCRIBE BELOW) NUTRITION ANTICIPATORY GUIDANCE AND SAFETY 13 Years Physical/skills develop Ht. Wt. BP Balanced diet Illicit drugs/alcohol/tobacco Emotional development Intellectual development General BMI Skin Genitalia Monitor snacks Home environment Puberty Date of Visit Social development HEENT Extrem Exercise Community Interests Teeth Nodes Chest Back Neuro Peer pressure Family dynamics Seat belt placement Heart Abdomen Vision test Dental care Fluoride Sun exposure Firearm safety Comments: Abnormalities: MVI Immunizations: Return_____________ Provider Initials______ DEVELOPMENTAL TASKS PRESENT NORMAL ABNORMAL (DESCRIBE BELOW) NUTRITION ANTICIPATORY GUIDANCE AND SAFETY 14 Years Physical/skills develop Ht. Wt. BP Cholesterol Illicit drugs/alcohol/tobacco Emotional development Education General Skin BMI Extrem Exercise Injury prevention; firearms Date of Visit Social relationships HEENT Back MVI Nutrition Teeth Nodes Chest Genitalia Neuro Pregnancy prevention Sexually transmitted diseases TSE/BSE Heart Abdomen Vision test Dental care Sun exposure Chlamydia/STD screening Pelvic exam Pap Immunizations: Comments: Abnormalities: Return_____________ Provider Initials______ DEVELOPMENTAL TASKS PRESENT NORMAL ABNORMAL (DESCRIBE BELOW) NUTRITION ANTICIPATORY GUIDANCE AND SAFETY 15 Years Physical/skills develop Ht. Wt. BP Cholesterol Illicit drugs/alcohol/tobacco Emotional development Education General Skin BMI Extrem evaluation Exercise Injury prevention; firearms Date of Visit Social relationships HEENT Back MVI Nutrition Teeth Nodes Chest Genitalia Neuro Pregnancy prevention Sexually transmitted diseases TSE/BSE Heart Abdomen Vision test Dental care Sun exposure Chlamydia/STD screening Pelvic exam Pap Immunizations: Comments: Abnormalities: Return_____________ Provider Initials______ [...].. .PEDIATRIC WELL CHILD CARE PATIENT’S NAME: DEVELOPMENTAL TASKS PRESENT 16 Years Date of Visit Physical/skills develop Emotional development Education Social relationships Comments: NORMAL ABNORMAL... ABNORMAL (DESCRIBE BELOW) Ht Wt General Skin HEENT Teeth Nodes Chest Heart Abdomen Pelvic exam Abnormalities: BP BMI Extrem Back Genitalia Neuro Vision test Pap NUTRITION Cholesterol evaluation MVI Dental care ANTICIPATORY GUIDANCE AND SAFETY Illicit drugs/alcohol/tobacco Exercise Injury prevention; firearms Nutrition Pregnancy prevention Sexually transmitted diseases TSE/BSE Sun exposure Chlamydia/STD... ABNORMAL (DESCRIBE BELOW) Ht Wt General Skin HEENT Teeth Nodes Chest Heart Abdomen Pelvic exam Abnormalities: BP BMI Extrem Back Genitalia Neuro Vision test Pap NUTRITION Cholesterol evaluation MVI Dental care ANTICIPATORY GUIDANCE AND SAFETY Illicit drugs/alcohol/tobacco Exercise Injury prevention; firearms Nutrition Pregnancy prevention Sexually transmitted diseases TSE/BSE Sun exposure Chlamydia/STD... ABNORMAL (DESCRIBE BELOW) Ht Wt General Skin HEENT Teeth Nodes Chest Heart Abdomen Genitalia Pelvic exam Abnormalities: BP BMI Extrem Back Neuro NUTRITION Cholesterol evaluation MVI Vision test Dental care Pap ANTICIPATORY GUIDANCE AND SAFETY Illicit drugs/alcohol/tobacco Exercise Injury prevention; firearms Nutrition Pregnancy prevention Sexually transmitted diseases TSE/BSE Chlamydia/STD screening... Immunizations: Return _ Provider Initials 2/94; REV.: 1/97; 3/98, 3/99, 5/02, 4/04, 6/05, 3/08, 4/09, 3/10, 4/12 T:\QM\TRANSFER\FORMS\PED CHART REVISED 6-05.DOC LAST PRINTED 5/30/2012 2:03:00 PM Health care benefit programs issued or administered by Capital BlueCross and/or its subsidiaries, Capital Advantage Insurance Company® and Keystone Health Plan® Central Independent licensees of the Blue Cross . SeniorBlue PPO) Child Health Maintenance Guidelines Pediatric Well Child Care Flow Sheets PEDIATRIC WELL CHILD CARE PATIENT’S NAME: ______________________________. Practice Guidelines 2013 Pediatric Well Child Care Flow Sheets PHYSICIAN GUIDELINES FOR PREVENTIVE