Office Visit Note
Narrative: CHIEF COMPLAINT Well-child visit for infant daughter, approximately 6-12 months old HISTORY OF PRESENT ILLNESS Infant presents for routine well-child visit. Parents report she is doing well developmentally. She is crawling and has recently started getting up on her knees to do a plank position. Motor skills are progressing appropriately. She is being introduced to solid foods including butternut squash, though parents note food sometimes falls out of her mouth as she is learning to manage textures. Family recently traveled to Arizona where there was significant elevation change (up to 6,000 feet) and very dry conditions. Parents noticed some hair loss/thinning on the right side of her head, which they attribute to her becoming more aware of her hands and brushing/touching her hair frequently. The family had a cold while in Arizona but the infant did not catch it. She is still breastfeeding. Sleep-wise, she co-sleeps with parents, sleeps through the night, rolls over to feed a few times and goes right back to sleep. Parents have been working on transitioning her to the crib - she will fuss for a bit but then falls asleep on her own. REVIEW OF SYSTEMS Constitutional: No reported illness, tolerating travel well. HEENT: No concerns reported. Respiratory: No respiratory illness despite family cold exposure. GI: Tolerating introduction of solid foods. Skin: Dry skin noted during Arizona travel with elevation changes. Neurological: Age-appropriate development, no concerns. PHYSICAL EXAM General: Well-appearing, interactive infant. Alert and engaging appropriately for age. Motor: Demonstrating age-appropriate motor skills - crawling, able to get up on knees to plank position. Good tone and strength observed. ASSESSMENT 1. Well-child visit, infant 6-12 months of age (ICD-10: Z00.129). Infant is meeting developmental milestones appropriately with crawling and beginning to push up on knees. Growth and development are progressing well. Parents engaged and attentive to feeding and sleep transitions appropriate for this developmental stage. PLAN Vaccines administered today per routine schedule for this age. Discussed developmental expectations for 6-12 month period including the transition from baby-directed feeding and sleep to more parent-established routines. Counseled on sleep training approaches - reassured parents that some self-soothing and brief fussiness when placed in crib is normal and helps infant learn to self-settle. Discussed solid food introduction - advised on appropriate texture and size for choking prevention, recommending finger-tip sized pieces that can be swallowed easily. Emphasized importance of ensuring adequate iron intake at this age through iron-fortified cereals or iron-rich foods like cheese, as iron stores from birth begin to deplete. Discussed that infants this age may be more reactive to vaccinations. Parents advised to take infant CPR class as recommended. ANTICIPATORY GUIDANCE Sleep training: Now is appropriate time to establish routines; some self-soothing and brief crying is normal and helps infant learn to fall asleep independently. Solid foods: Continue introducing variety of foods with appropriate textures; use finger-tip sized pieces to reduce choking risk. Development: Expect increased communication attempts and more awareness of routines. Safety: Infant CPR class recommended given increasing mobility and solid food introduction. Nutrition: Ensure adequate iron intake through fortified foods or iron-rich options. FOLLOW-UP Return for next scheduled well-child visit ICD-10 CODES Z00.129 - Encounter for routine child health examination without abnormal findings CPT CODES 99391 - Periodic preventive medicine visit, established patient, infant (age younger than 1 year) ───────────────────────────────────────── CODES: CPT 99391 | ICD-10 Z00.129