Office Visit Note
Reason: Office Visit Narrative: SUBJECTIVE: Chief Complaint: 3-year well child check. HPI: Here for routine WCC. Parent reports child is doing well with no current concerns. Eating and sleeping well, active, and growing well (per parent report). ROS: No fever, no respiratory symptoms, no GI complaints. No concerns with hearing or vision noted. Development: Gross motor: Runs, climbs, and jumps with good coordination. Fine motor: Builds towers, copies simple shapes, uses utensils appropriately. Language: Speaks in sentences, follows multi-step commands, speech mostly understandable. Social/emotional: Engages in cooperative play, imitates adults, shows a range of emotions. PMH/FH/SH: No new issues reported. ⸻ OBJECTIVE: Vitals: [not documented] Physical Examination: General: Well-appearing, playful, no acute distress. HEENT: Normocephalic, TMs clear, oropharynx moist without lesions. Eyes: PERRL, conjunctiva clear, normal ocular alignment (grossly). Neck: Supple, no lymphadenopathy. Cardiovascular: RRR, no murmur. Respiratory: Lungs clear, no increased work of breathing. Abdomen: Soft, non-tender, no masses. GU: Normal external genitalia (visual exam only). Skin: No rashes or lesions. Neuro: Normal tone and gait for age. MSK: Full range of motion, no deformities. ⸻ ASSESSMENT: 1. Encounter for well child exam with abnormal findings: none (ICD-10: Z00.129) Healthy 3-year-old with appropriate growth and development by report and exam. ⸻ PLAN: Discussed age-appropriate nutrition with emphasis on balanced meals, variety, and limiting sugary drinks. Reviewed sleep routines, toilet training progress, and behavioral guidance including consistent limits and positive reinforcement. Encouraged daily active play and limiting screen time. Reviewed safety: car seat use, supervision around water, and safe home environment. Provided return precautions for any new concerns regarding growth, behavior, or illness. Plan for routine follow-up at 4 years or sooner as needed. CPT: 99392 ⸻ FOOTER: CODES: CPT 99392 | ICD-10 Z00.129 [routine normal findings assumed unless specified]