Well Child Care Visit Sample

                                                          WELL CHILD CARE VISIT

 

Patient Name: _____________________________ DOB:__________________  Date: _______________

 

Height: __________ Weight: ­­­­­­­___________ BMI % (<18 yo) _________ BMI Value (18 yo+) ___________

 

 

E&M/Office Visit Level:
Office/Other Outpatient Visit		New Pt	Established Pt
	1-4 years old	99382	99392
	5-11 years old	99383	99393
	12-17 years old	99384	99394
	>18 years old	99385	99395
	Telehealth modifier: GT or 95 (audio and video)

 

BMI Percentile Dx Codes (<18 years old)
	Z68.51	<5th percentile
	Z68.52	5th percentile to <85th percentile
	Z68.53	85th percentile to <95th percentile
	Z68.54	>95th percentile

  

BMI Value Dx Codes 18+ year old:
	Z68.1: 19.9 or less		Z68.24: 24.0-24.9		Z68.29: 29.0-29.9		Z68.34: 34.0-34.9		Z68.39: 39.0-39.9		Z68.45: 70 or greater
	Z68.20: 20.0-20.9		Z68.25: 25.0-25.9		Z68.30: 30.0-30.9		Z68.35: 35.0-35.9		Z68.41: 40.0-44.9
	Z68.21: 21.0-21.9		Z68.26: 26.0-26.9		Z68.31: 31.0-31.9		Z68.36: 36.0-36.9		Z68.42: 45.0-49.9
	Z68.22: 22.0-22.9		Z68.27: 27.0-27.9		Z68.32: 32.0-32.9		Z68.37: 37.0-37.9		Z68.43: 50.0-59.9
	Z68.23: 23.0-23.9		Z68.28: 28.0-28.9		Z68.33: 33.0-33.9		Z68.38: 38.0-38.9		Z68.44: 60.0-69.9

 

Lead Screening (under 2 Yrs. of Age):     ______________________________________________________________________________

 

Smoking:

Was the patient queried about smoking behavior?  ⃝ Yes     ⃝ No

Does the patient currently smoke?  ⃝ Yes     ⃝ No

 

Depression Screening:

 

1. Little interest or pleasure in doing things? ⃝ Always     ⃝ Sometimes     ⃝ Never

 

2. Feeling down, depressed, or hopeless? ⃝ Always     ⃝ Sometimes     ⃝ Never

 

Result:   ⃝ Positive ⃝ Negative

 

Anticipatory Guidance:

Nutrition:                           

3 meals a day?  ⃝ Yes     ⃝ No

                                                Healthy snack choices?  ⃝ Yes     ⃝ No

                                                Avoiding junk food?  ⃝ Yes     ⃝ No

                                                Avoiding whole milk?  ⃝ Yes     ⃝ No

                                                Healthy eating?  ⃝ Yes     ⃝ No

                                                Positive body image?  ⃝ Yes     ⃝ No

Iron source? ______________________________________________________

Physical Activity:                  

                                                Exercise Type _____________________________________________________                                                  Extracurricular Activity/Sports ________________________________________

                                                Screen Time ______________________________________________________

 

Social Determinants:     

Living Situation ____________________________________________________

                                                Food Security _____________________________________________________

                                                Interpersonal Violence ______________________________________________

                                                Family Substance Abuse _____________________________________________

 

Dental Care ___________________________________________________________________________

Elimination ___________________________________________________________________________

Sleep ________________________________________________________________________________

Sexual Behavior ________________________________________________________________________

School _______________________________________________________________________________

Mental Health _________________________________________________________________________

Emotional Well-Being ___________________________________________________________________

 

Ability to get along with others?  ⃝ Yes     ⃝ No

Controls emotions?  ⃝ Yes     ⃝ No

Exhibits compassion and empathy?  ⃝ Yes     ⃝ No

 

Safety:

1. Bicycle/helmet?
2. Use of booster seat?
3. Fire Safety?
4. Injury Prevention?

 

Social History:

Smoke Free Home: _____________________________________________________________________

 

Father’s History: _______________________________________________________________________

 

Mother’s History: ______________________________________________________________________

 

ROS/Exam:

Const

Head/Face

Eyes

ENMT

CV

Resp

GI

GU

Integumentary

Musculo-Skeletal

Neuro