Office Visit Note
Narrative: CHIEF COMPLAINT Well child visit with Hib vaccine administration HISTORY OF PRESENT ILLNESS Daisy is a 1-year-old female presenting for a well child visit. She recently turned 1 year old. Mom reports she is now walking. Mom notes that Daisy seems short compared to her sibling but acknowledges the sibling was always big. Mom asks about car seat transition, specifically whether to wait until Daisy outgrows the length requirements for the infant car seat. Mom also recalls that after the last vaccine visit (MMR and varicella), Daisy had a difficult week with possible fever, though mom is unsure if it was vaccine-related or a coincidental illness. No acute concerns are raised today. ASSESSMENT 1. Well child visit, approximately 1 year old 2. Hib vaccination administered today 3. Parental concern regarding short stature relative to sibling PLAN 1. Well child visit: Routine preventive care provided. Developmental milestone of walking noted and appropriate for age. 2. Hib vaccine administered today. Vaccine education provided including discussion of potential side effects: local reaction with redness at injection site and possible fever. Counseled that risk of local reaction may increase with subsequent doses. Parents advised that fever, if it occurs, would be expected shortly after vaccination (not delayed as with MMR/varicella). Education provided regarding the purpose of the Hib vaccine (protection against Haemophilus influenzae type b and meningitis), with discussion that these infections are most common in children under 3 years of age. 3. Growth concern: Mom expressed concern that Daisy appears short. Reassurance provided in context of comparison to sibling who was always large. ANTICIPATORY GUIDANCE Car seat safety discussed. Addressed parent question regarding transition out of the infant car seat. General guidance on recognizing signs of serious illness discussed, including what true lethargy looks like in a child versus normal tiredness. Encouraged parents to trust their instincts and seek care when concerned, emphasizing that it is better to be more cautious early on. FOLLOW-UP Routine well child follow-up as appropriate per schedule. ICD-10 CODES Z00.129 - Encounter for routine child health examination without abnormal findings Z23 - Encounter for immunization CPT CODES 99391 - Preventive medicine, established patient, infant (age under 1 through 4 years) ───────────────────────────────────────── CODES: CPT 99391 | ICD-10 Z00.129, Z23