Office Visit Note
ElationNoteColOne: HPI: Hpi: * General well visit * Here for 6-month well visit with her mother * Growing and active; described as great and smart with excellent social and motor skills * Crawling; can get up on knees and plank * Increased energy but still takes long naps Hpi: * Cradle cap * Mild yellow cradle cap noted on scalp; parent reassured it’s normal Hpi: * Facial pink spots * Intermittent small pink spots on forehead when upset or teething Hpi: * Nevus simplex * History of nevus simplex noted by clinician in context of facial pink spots Hpi: * Ear brushing * Parent noticed baby brushing right ear frequently during recent Arizona trip with elevation changes and dry climate * Parent thinks ears look fine; no additional ear symptoms reported Hpi: * Feeding * Exclusively breastfed; no formula * Started solids: mashed banana, avocado, sweet potato, squash/butternut squash * Learning to manage solids; food sometimes falls out of mouth * Discussed choking risk, appropriate textures, and volumes Hpi: * Sleep * Sleeps with parents; sleeps through night; occasionally feeds and returns to sleep * Wakes around 7 AM; prefers contact naps * Parents considering sleep training and self-soothing strategies Hpi: * Recent travel * Arizona up to ~6000 ft elevation * Parents had a cold; patient did not Hpi: * Safety and education * Discussed choking prevention and infant CPR class (parent plans to take) * Discussed routine/behavioral boundaries appropriate for age ElationNoteColOne: Allergies: Allergies: * eat my shots really not ElationNoteColOne: Reconciled Medications: Med: * None stated ElationNoteColOne: Social History: Social: * Lives with parents; recent travel to Arizona ElationNoteColTwo: Data: Data: * Developmental observations during visit (social and motor skills) ElationNoteColTwo: PE: PE: - General: Alert, interactive; doing well - Eyes: History of nevus simplex discussed; no acute eye concerns on exam - HENT: Scalp with mild yellow cradle cap; ears externally appear normal per parent; no abnormal ear findings documented - Resp: Normal effort; lungs without noted abnormalities - CVS: Heart sounds good on auscultation - Skin: Intermittent pink forehead spots when upset/teething - Psych: Age-appropriate social engagement; social skills excellent ElationNoteColTwo: Assessment & Plan: Assessplan: * Encounter for routine child health examination without abnormal findings Assessplan: * Cradle cap Assessplan: * Nevus simplex Assessplan: * Breastfed infant—need for iron supplementation counseling Assessplan: * Teething Assessplan: * Immunization encounter ElationNoteColTwo: Procedures: Procedure: * Immunizations administered: oral rotavirus and three injections (six-month series: Pentacel and Prevnar) ElationNoteColTwo: Follow Up: Followup: Return in 3 months for next well visit