Office Visit Note
Reason: Office Visit Narrative: SUBJECTIVE: Chief Complaint: 12-month well child visit. HPI: Parent reports he is healthy overall with no current concerns. Eating a good variety of table foods (per parent report), drinking appropriate amounts, normal urine/stool patterns, and sleeping well. No recent illnesses or injuries. ROS: No fever, cough, breathing difficulty, vomiting, diarrhea, rash, or concerns for hearing or vision. Development: Gross motor: pulls to stand, cruises, beginning to take steps with support. Fine motor: mature pincer grasp, feeds self small pieces, purposeful release. Language: specific “mama/dada,” a few additional words or word-approximations (per parent report), follows simple commands. Social/emotional: waves, imitates, engages in interactive play, seeks caregiver reassurance appropriately. PMH/FH/SH: Noncontributory as reported. ⸻ OBJECTIVE: Vitals: [not documented] Physical Examination: General: Well-appearing, alert, no acute distress. HEENT: Normocephalic, anterior fontanel appropriate; TMs clear; nares patent; oropharynx moist without lesions. Eyes: Conjunctiva clear; normal red reflexes. Neck: Supple, no masses. Cardiovascular: RRR, no murmur; good peripheral pulses. Respiratory: Clear breath sounds, no increased work of breathing. Abdomen: Soft, non-tender, no organomegaly. GU: Normal male genitalia, testes descended bilaterally. Skin: No rashes, lesions, or bruising. MSK: Normal tone and movement; no deformities. Neuro: Alert, normal strength and symmetry; age-appropriate gross and fine motor skills. ⸻ ASSESSMENT: 1. Encounter for routine child health examination without abnormal findings (ICD-10: Z00.129) Child growing and developing appropriately with a normal exam. No concerns raised today. ⸻ PLAN: Discussed age-appropriate anticipatory guidance including safety with walking and climbing, rear-facing car seat, choking prevention, and consistent routines for sleep. Reviewed expected developmental gains and typical eating patterns as appetite becomes more variable. Encouraged transition toward whole milk and continued offering of diverse textures and flavors. Reviewed dental hygiene with twice-daily brushing using a smear of fluoride toothpaste. Provided routine 12-month immunizations per schedule. Advised to return sooner for any fever persisting, decreased intake, decreased urine output, rash with systemic symptoms, or parental concern. Follow up at 15 months for next well visit. CPT: 99392 ⸻ FOOTER: CODES: CPT 99392 | ICD-10 Z00.129 [routine normal findings assumed unless specified]