Outpatient
Agenda setting
Low risk procedure, e.g. cataract surgery requires no preoperative testing as cardiac risk is < 1%
Higher risk procedures require further evaluation.
Post-operative visit: More coming soon…
Inpatient: Discharge dictation
Newborn screen: Congenital heart disease
Well child check templates
[Age] year old [gender] presents for HME
#Vaccination (≥ 22 y/o)
Influenza season: Administer influenza vaccine
Most recent TDaP ≥ 10 years ago: Administer TD booster
≤ 26 y/o with no history of HPV immunization and not currently pregnant: Administer 1st dose HPV vaccine and follow up in 2 to 6 months for the 2nd, 3rd dose
≥ 50 y/o with no history of HZV immunization, immunocompromised state: Administer 1st dose Shingrix (RZV) vaccine, follow up in 2 to 6 months for 2nd dose
≥ 65 y/o: Administer 1 dose Pneumococcal polysaccharide vaccine (PPSV23)
Born after 1980 with no varicella immunity and not currently pregnant: Administer 1st dose varicella vaccine, follow up in 4 to 8 weeks for 2nd dose
Born after 1957 and not currently pregnant: Ensure patient has received at least one MMR vaccine
Chronic disease or other risk factors (any age)
PPSV23 and HepB
Diabetes mellitus
Chronic liver disease: Add HepA
ESRD on hemodialysis: Add PCV13
HIV: Add PCV13, MenACWY
Asplenia: PCV13, PPSV23, MenACWY, Hib
#Depression screen: Perform PHQ-2
PHQ-2 score ≥ 3: Perform PHQ-9
PHQ-9 score ≥ 10 (moderate/severe): Discuss starting SSRI
#Alcohol use: Counsel about appropriate intake limits for age and sex
#Tobacco use: Perform tobacco cessation counseling lasting ≥ 3 minutes
Smoking cessation pharmacotherapy (select one)
Start nicotine patch
No history of mental illness, suicidal ideation: Start varenicline 1 week before quit date (0.5 mg qd days 1-11, 1 mg qd days 12-42). Follow-up in 12 weeks to review continuation for an additional 12 weeks.
Start bupropion SR 150 mg qd days 1-3 then increase to 150 mg BID
55-80 y/o with ≥ 30 pk/yr history, smoked within past 15 years, and candidate for lung surgery: Refer for yearly low-dose CT
65-75 y/o male with who has ever smoked: Refer for one-time AAA U/S screening
#STI/ID
Age 15-65 years: Screen for HIV
Engaged in high-risk sexual behaviors: Screen for hepatitis B, syphilis and offer preexposure prophylaxis (PrEP) therapy
At increased risk for TB: Place PPD and follow up for read in 48-72 hours
#Obesity (BMI > 30 kg/m2): Perform brief counseling about diet and exercise. Refer for further behavioral/dietary counseling.
#HTN: Repeat BP in office >140/>90. Trial of lifestyle modification and follow-up in 1-3 months. If BP still elevated, start antihypertensive therapy (select one):
Amlodipine 5 mg qd
Chlorthalidone 25 mg qd and obtain BMP in 2 weeks
History of HF, left ventricular hypertrophy, MI, DM, ADPKD and no history of CKD: Start lisinopril-HCTZ 10-12.5mg qd and obtain BMP in 2 weeks
#Skin cancer prevention in fair-skin patient ≤ 24 y/o: Counsel about UV radiation and sunscreen use
#DM screening (40-70 y/o with BMI > 30 kg/m2): Obtain HbA1c
#Lipid screening (40-75 y/o): Obtain lipid panel and repeat every 3 years if not already taking a high-intensity statin
#Statin therapy: 40-75 y/o with CVD risk factor (MI/stent/angina, CVA, DM, PAD, HTN, smoking) and/or ASCVD risk > 10%. Start statin therapy.
#Aspirin therapy: 50-59 y/o with life expectancy > 10 years, willing to take aspirin for > 10 years, and ASCVD > 10%. No history of GI bleed, coagulopathy, or other bleeding risk. Start aspirin 81mg qd for prevention of CV disease, colon cancer.
#Colon cancer screen (50-75 y/o): Colorectal CA screening with FIT every 1 year or colonoscopy every 10 years.
#Hepatitis C Screen: Born between 1945-1965 with no previous h/o Hep C screening. Obtain one time hepatitis C screen.
#Age > 65 years and at increased risk for falls: Recommend exercise interventions for fall prevention.
#Age 18-65 years
≤ 24 y/o and sexually active: Screen for chlamydia/gonorrhea infection
Capable of pregnancy: Start 0.4 mg folic acid daily
Domestic violence screen: Patient feels safe at home
#Cervical cancer screen
21-29 y/o: Perform Pap q3 years
30-65 y/o: Perform Pap with co-testing q5 years
#Breast cancer screen
Age ≥ 35 years with family h/o breast, ovarian, tubal, or peritoneal cancer: Administer screening tool, e.g. Pedigree Assessment Tool to assess need for genetic counseling, BRCA screening
Age >50 years: Mammogram every 2 years
No prior breast CA diagnosis and at increased risk: Administer screening tool to assess benefit/risk of tamoxifen/raloxifene therapy. If screening positive and patient willing to undergo treatment, consider tamoxifen 20mg vs. raloxifene 60 mg x 5 years
#Osteoporosis Screen: Age ≥ 65 years and/or positive osteoporosis risk assessment tool. Obtain DEXA scan.
Second doses of HZV (Shingrix) and VZV may be administered 2 months following the first dose
Adults born before 1957 are consider MMR immune with the exception of health care workers
Vaccines are often referred to by trade names
Definition of ever smoke is 100 cigarettes in a lifetime (see AAA screening for males age 65-75 years)
Examples of high risk sexual behaviors include
Multiple sexual partners
Any sexual activity (oral, genital, anal)
Before the age of 18
With a non-monogamous partner and without the use of a condom or barrier protection
With a high risk partner, i.e. someone with a history of sex work and/or IV drug use
There are no clear guidelines concerning repeat lipid screening. Repeating every 3 years is a conservative recommendation per expert opinion.
Source: Journal of the American College of Cardiology. Volume 64, Issue 22, December 2014. DOI: 10.1016/j.jacc.2014.07.944
Surgery to be performed:
Date of surgery:
Surgeon:
Surgeon’s fax number:
Identify CAD Risk factors that increased risk of MACE
Age 55 years or older
History of
Cigarette smoking within the previous 6 months
Unstable angina, i.e. chest discomfort/pain with exertion
HTN, HLD (LDL > 190), arrhythmia, HF, MI, CKD, DM, PAD, stroke
Cardiac revascularization within the previous 5 years
Family history of HLD, MI, stroke
Functional capacity: Evaluate if any MACE risk factors are positive
< 4 METs: Cannot walk up 1 flight of stairs
4-10 METs: Walk uphill for 1-2 blocks and/or 1 flight of stairs without stopping
> 10 METs: Strenuous sports (swimming, cycling, tennis, soccer)
Additional history for consideration:
Allergies and medications
Current medical issues (including pregnancy) and/or history of
Asthma, COPD, lung disease
Sleep apnea including STOP-BANG score
Anemia, bleeding, and/or clotting disorders
Previous surgeries including dates and complications
Previous anesthesia and complications
Alcohol and/or recreational drug use
Home environment and social support
Where and with whom does the patient live?
Are there stairs in the living environment or other potential hazards?
What are the patient’s plans for transportation to and from the surgery?
BP, BMP, O2 saturation
Dental examination
Cardiopulmonary examination
Presence of CAD risk factors: Calculate Major Adverse Cardiac Event (MACE) Risk
Risk of cardiac complication less than 1% or > 4 METS: Proceed to surgery
< 4 METs: Refer for pharmacologic stress testing
Cardiac Risk Identified
Unstable angina: Obtain EKG and refer for stress test
Negative stress test: Evaluate risk per surgical calculator
Positive stress test: Refer to cardiology for further evaluation
Arrhythmia: Perform EKG and consider further workup pending rhythm
Delay elective surgery for
Smoking within 8 weeks
Recent CAD intervention including angioplasty (within 14 days), bare metal stent (30 days), or drug-eluting (1 year)
Medications:
Stop
Now: OTC herbal supplements, bisphosphonates
7 days before procedure:
Aspirin (unless indication is prior coronary artery stenting)
P2Y12 inhibitor (e.g. clopidogrel)
5 days before procedure: Warfarin if no h/o mechanical heart valve and/or DVT/PE within previous 3 months (otherwise bridging with LMWH required)
3 days before procedure: Dabigatran, COX-2 inhibitors, NSAIDs
24 hours before surgery:
NOACs (e.g. apixaban, rivaroxaban)
Oral diabetes medications (administer 50% basal insulin dose morning of procedure)
Continue
Continue dual antiplatelet therapy (e.g. clopidogrel and aspirin) if < 6 weeks s/p bare metal stent or < 1 year s/p drug eluting stent
Beta-blockers if started > 4 weeks before surgery
Administer
Stress dose steroids for chronic prednisone > 5 mg/day: Hydrocortisone 75 mg IV q8 hours
Dental prophylaxis (administer 2g amoxicillin 1 hour prior to surgery) for h/o unrepaired congenital heart disease, infective endocarditis, prosthetic heart valve, heart transplant, major heart surgery within previous 6 months
Patient determined to be at above average risk by American College of Surgeons Surgical Risk Calculator
PNA or pulmonary complications: Obtain CXR
Surgical site infection: Obtain HbA1c
U/A: Current s/sx UTI, planned urologic intervention, planned implantation of foreign material
Renal failure: Consider nephrology consult
Death: Reconsider surgery
Obtain for the following issues or if requested by the surgeon
CBC: Age > 65, anemia, CKD, liver disease, cardiac/vascular surgery
CMP
HTN, HF, CKD, DM, liver disease
Use of chronic NSAID, diuretics, ACE/ARB, digoxin
HbA1c: DM
PT/PTT/INR: Anemia or taking anticoagulants
Urine pregnancy test: Female of childbearing age
CXR: Age > 60, COPD, HF, planned intrathoracic surgery
Cervical Spine x-ray: H/o rheumatoid arthritis due to risk for atlanto-axial subluxation during intubations
EKG: Obtain for CAD, PAD, CVA, arrhythmia
LBBB: Refer for stress test
Other abnormalities: Consider obtaining echocardiogram/stress test vs. referral to cardiology
Echocardiogram: Valvular disease with most recent study > 1 year prior
Patient counseled to stop smoking and consider delaying elective surgery until 8 weeks after successful smoking cessation
H/o sleep apnea: Patient should bring oral appliance and/or CPAP machine on day of surgery
NPO instructions (often institution-dependent): 2 hours for clear liquids, 4 hours for breast milk, 8 hours for meals
Not required for healthy patients receiving topical/local anesthesia, nitrous oxide/oxygen for a dental procedure, and/or peripheral nerve blocks
Previous MI risk classification for procedures included
Low (< 1%): Cataract, breast, EGD/colonoscopy
Intermediate (1-5%): Head/neck, intrathoracic, intraperitoneal including prostate, orthopedic
High (> 5%): Vascular surgery, emergent procedures
Previous MI
Non-emergent surgery should not be performed within 60 days of MI
CVD risk increases if MI occurred within the previous 6 month
Heart failure
Increases peri/postoperative mortality risk to 50 to 100%
Greater risk associated with HFpEF
Risk for pulmonary complications is increases with length of surgery
Medications
Statins reduce 30 day MI and death rates
Steps for warfarin bridge:
Stop warfarin 4 days before procedure and start LMWH
Stop LMWH 12 hours before procedure and restart 6 hours after procedure
Restart Warfarin when no longer NPO and stop LMWH when INR > 2.0
Postoperative fever and complications
Fever mnemonic (7 Ws): Wind (see pulmonary below), water (UTI), wound (surgical site), walking (PE), wonder drugs, withdrawal, wonky gland (endocrine)
Pulmonary
Conditions: Atelectasis, PNA, PE
Prevention: Preoperative steroids, incentive spirometry, DVT ppx including ambulation
Infection: PNA, UTI, surgical site
Prenatal visit: _ y/o G-TPAL at _ WGA by _ with [current complications] presents for prenatal visit. [Previous complications].
LMP date:
Lab work
Urine (2 labs): Urine pregnancy (beta-hCG qualitative), urine culture
Bloodwork (3 labs): CBC, blood type, Rh antibody screen
Infectious disease screen (6 labs)
Viruses with associated immunizations (3 labs): Rubella antibodies, varicella IgG, Hepatitis B surface Ag
STIs (3 labs): Gonorrhea/Chlamydia NAAT, RPR/Reflex FTA-ABS, HIV 4th Generation EIA
Additional testing
No Pap within 3 years or no Pap/co-testing within 5 years: Perform Pap
Pt counseled about genetic (aneuploidy) testing
Ultrasound at 8-12 WGA shows [] WGA fetus per [gestational sac, crown rump length]
Treatment
Administer seasonal influenza vaccine
Start prenatal vitamin
Treat nausea due to pregnancy
F/u every 4 weeks until 28 WGA
Prenatal visit: _ y/o G-TPAL at _ WGA with [current complications] presents for prenatal visit. [Previous complications].
> 14 WGA; fetal heart tones _ by Doppler
Refer for anatomy scan to be performed at 18-20 WGA
Prophylaxis per risk factors
H/o preeclampsia: Aspirin 81 mg from 12 to 39 WGA
H/o spontaneous preterm birth with no maternal h/o HTN, seizure disorder and no known fetal anomaly: Weekly hydroxyprogesterone caproate supplementation (Makena) from 16 to 36+6 WGA
Provided with birthing class pamphlet
F/u every 4 weeks until 28 WGA
Prenatal visit: _ y/o G-TPAL at _ WGA with [current complications] presents for prenatal visit. [Previous complications]. Fundal height consistent with dates.
Fetal heart tones _ by doppler
24 WGA: Repeat CBC and perform 1 hour glucose tolerance test (GTT)
28 WGA:
Administer TDaP
Maternal blood type Rh negative:
Repeat antibody screen
Administer anti-D immune globulin (RhoGAM) 300 mcg IM after antibody screen is drawn
Prophylaxis
H/o preeclampsia: Continue aspirin 81 mg from 12 to 39 WGA
H/o preterm birth: Continue Makena from 16 to 36+6 WGA
Delivery and postpartum
Pt desires TOLAC: Refer for OB consult
Counseled about postpartum birth control
F/u every 4 weeks until 28 WGA
Prenatal visit: _ y/o G-TPAL at _ WGA with [current complications] presents for prenatal visit. [Previous complications]. Fundal height consistent with dates.
Fetal heart tones _ by doppler
28 WGA:
Administer TDaP
Maternal blood type Rh negative:
Repeat Rh antibody screen
Administer anti-D immune globulin (RhoGAM) 300 mcg IM after Rh antibody screen is drawn
36 WGA: Perform GBS swab, repeat HIV test. Repeat G/C if risk factors present.
Prophylaxis
H/o preeclampsia: Continue aspirin 81 mg from 12 to 39 WGA
H/o preterm birth: Continue Makena from 16 to 36+6 WGA
Delivery and postpartum
Discussed s/sx of labor and plans for delivery
Counseled about postpartum birth control
F/u every 2 weeks until 36 WGA
Prenatal visit: _ y/o G-TPAL at _ WGA with [current complications] presents for prenatal visit. [Previous complications]. Fundal height consistent with dates.
Fetal heart tones _ by doppler
Fetus vertex by U/S
36 WGA: Perform GBS swab and repeat G/C if risk factors present
Prophylaxis
H/o preeclampsia: Continue aspirin 81 mg from 12 to 39 WGA
H/o preterm birth: Continue Makena from 16 to 36+6 WGA
Delivery and postpartum
Discussed s/sx of labor and plans for delivery
40 WGA: Schedule IOL for 41 WGA
Counseled about postpartum birth control
F/u every week until delivery
≥ 6 months: Oral fluoride supplementation if water supply is fluoride deficient
6 months to 24 years with fair-skin: Counsel about UV radiation, skin cancer, and sunscreen use
3 to 5 years: Vision screening for amblyopia, vision loss
≥ 6 years and obese (≥ 95th percentile): Offer intensive behavioral interventions to promote improvements in weight status
≥ 12 years: Depression screening
≥ 15 years: Screen for HIV
Sexually active
Counsel about risk for STIs
High risk activity: Screen for hepatitis B, syphilis and offer PrEP therapy
Females ≤ 24 years: Screen for gonorrhea/chlamydia. Adult recommendations concerning intimate partner violence screening, folic acid supplementation apply.
Cow’s milk recommendations
< 1: No cow’s milk
1-2 years: 8 oz whole milk daily
2-8 years: 16 oz 2% milk daily
8-18 years: 24 oz 2% milk daily
Sleep recommendations (per day) ≈ (14 - age in years) hours/day until 4 years old and then ≥ 10 hours/day until a teenager
4-12 months: 12-16 hours
1-2 years: 11 to 14 hours
3-5 years: 10-13 hours
6-12 years: 9-12 hours
13-18 years: 8-10 hours
Eye deviation: Refer to ophthalmology at age 6 months
Vitamin supplementation until age 6 months for breastfed infants
Vitamin: 400 IU/day
Iron 1 mg/kg/day
Fluoride supplementation for deficient water supplies
0 to 6 months: None
6 months to 3 years: 0.25 mg/day
3 to 6 years: 0.5 mg/day
6 to 16 years: 1 mg/day
Influenza vaccine
Age
6 months to 2 years: Inactivated vaccine
2 to 18 years: Live attenuated vaccine
18 years and older: Recombinant vaccine
One vs. two doses: Any child 8 years or younger who has received < 2 lifetime doses: Administer first dose now followed by 2nd dose in 4 weeks
Additional Resources
CDC: Milestone assessment and pediatric vaccination schedule
General Assessment
For Parents: Toilet training and a resource for providers/parents (Katherine Osman, editor Giselle May)
2 year
Bright Futures 2 year handout
2.5 year: See Bright Futures Pocket Guide
3 year
Bright Futures 3 year handout
4 to 5 years
6 to 8 years
11 to 12 years: See Bright Futures Pocket Guide
12 to 18 years: See Bright Futures Pocket Guide
A Guide for Office Vaccines
Pediatric influenza vaccination guidelines for children age 6 months through 8 years. Source: DCDC Prevention and Control of Seasonal Influenza with Vaccines: Recommendations of the Advisory Committee on Immunization Practices—United States, 2018–19 Influenza Season.
A Guide for Office Vaccines
Number of doses
4 dose = P vaccines (PCV13, Polio)
5 dose = DTap (D is the Roman numeral for 500)
2 dose = HAMMR Varicella at 1 (all), 2 (Hep A), and 4 years (MMR, varicella)
Last doses
6 months = Hep B and rotavirus
1 year = PCV 13 and HIB
4 years = Polio and DTaP
Individual vaccines
Influenza (Fluzone Quad)
Ages 6 to 35 months: Administer 0.25 mL
Age 36 months or older: Administer 0.5 mL
See algorithm (right) for information concerning the administration of 1 versus 2 doses in children younger than 9 years
HPV: Administer 1 dose at the 11 and 12 year old well child checks
The meningococcal B vaccine is CDC approved, but not mandatory
Screen for congenital hypothyroidism and sickle cell disease
Apply topical ocular medication to prevent gonococcal ophthalmia neonatorum
Parental concerns:
General health
No new allergies, medications, health issues
No parental concerns regarding vision, hearing
Nutrition: On average, gaining 15-30 g/day during first six months of life
Breastfed
Concerns about breastfeeding:
Nurses q2-3 hours (8-12x daily) for 5-20 minutes per breast
Receives 400 IU vitamin D supplementation daily
Formula fed
Two scoops 20 kCal/oz formula added to 2 oz water
Water is measured before formula powder is added
Elimination: ≥ 6 wet diapers and ≥ 1 stool(s) qd; stools appear []
Sleep: Sleeps 14 to 17 hours daily
Social history
Mother denies postpartum depression
Activities/childcare during day:
Developmental milestones
Anticipatory guidance
No shaking infant
Sleep on back in bassinet/crib with no blankets, bumpers, toys
No smoking in home and change clothes after smoking outside
Rear facing car seat until age ≥ 2
General Health
Maternal PHQ-9 < 10
Acute health issues:
Vision/hearing concerns: Refer to ophthalmology/audiology
Nutrition concerns
Continue vitamin D 400 IU qd until infant is weaned or consuming > 32 oz (1 L) fortified formula daily
Elimination
Anticipatory guidance: Counseled about appropriate screen time, water safety, car safety, and gun safety
Vaccinations: 1st dose hepatitis B if not administered in hospital
Vaccinations
Not achieving developmental milestones:
Nutrition: Appropriate weight gain is the best indicator of adequate nutrition
Formula
Standard formula is 20 kCal/oz
Water should be measured before formula is added
Average energy requirements by age
0 to 1 month: 110 kCal/day
1 to 3 months: 95 kCal/day
6 to 12 months: 80 kCal/day
Stools: Generally yellow/seedy in breast fed infants and may be green in formula fed infants
Parental concerns:
General health
No new allergies, medications, health issues
No parental concerns regarding vision, hearing, oral health
Most recent dentist visit:
Nutrition: Consumes balanced diet that includes fruits, vegetables, protein, iron rich foods, and < 20 oz 2% milk daily
Elimination: Regular voids and no constipation; has not started toilet training
Sleep: Regular bedtime and naps; sleeps 11 to 14 hours daily
Social history
Activities/childcare during day:
No parental concerns about behavior, temperament
M-CHAT-R/F administered
Developmental milestones
Uses at least 50 words and 2-word phrases
Imitates adults and plays pretend alongside other children
Follows 2-step commands
Draws with crayon
Stacks 5 or 6 blocks
Goes up and down stairs one step at a time
Anticipatory guidance
Screen time < 2 hours daily
Always supervised when outside and/or near water
Uses rear-facing car seat
Firearms in household stored unloaded in firearm safe with ammunition stored separately
General Health
Acute health issues:
Vision/hearing concerns: Refer to ophthalmology/audiology
Oral health
Encouraged twice yearly dental visits
Water source does not contain fluoride: Fluoride drops 0.25 mg/day
Nutrition concerns, low iron intake, and/or consuming > 20 oz milk daily: Obtain CBC
Elimination
Functional constipation: Trial of 4 ounces diluted fruit juice daily; f/u in 2-4 weeks if symptoms persist
Toilet training
Insufficient verbal/motor skills to indicate need to void/use potty: Delay toilet training
Child ready for toilet training: Parents encouraged to visit https://www.healthychildren.org/English/ages-stages/toddler/toilet-training/Pages/default.aspx for more information
Anticipatory guidance: Counseled about appropriate screen time, water safety, car safety, and gun safety
Vaccinations/Universal Screening
Vaccinations
Administer hepatitis A vaccine
Live attenuated influenza vaccine
Pt has received < 2 lifetime doses: Administer first dose now followed by second dose in 4 weeks
Pt has received ≥ 2 lifetime doses: Administer 1 dose
Obtain lead level
M-CHAT-RF
0-2: Normal screen; repeat at age 3 years
3-7: Positive M-CHAT-R/F responses reviewed; upon clarification
Score < 2: Repeat at age 3 years
Score remains ≥ 2 with provider concern based on observation: Refer to developmental pediatrics
8-20: Refer to developmental pediatrics
Not achieving developmental milestones:
No previous missed milestones: Reassess in 6 months and refer to early intervention resources and/or medical specialist if issues persist
Persistent developmental delay: Refer to early intervention resources and/or medical specialist
Diet
Iron rich foods include meat, eggs, beans, and iron-fortified cereals
At age 2, children should begin consuming 2% milk
Child should remain in rear facing car seat until age 2
May transition to forward-facing car seat when child exceeds weight limit of rear-facing seat
Child should remain in forward facing car seat (not booster seat) until age 5 years
MCHAT scoring
1 point for YES on items on 2, 5, and 12
1 point for NO on all other items
Parental concerns:
General health
No new allergies, medications, health issues
No parental concerns regarding vision, hearing, oral health
Most recent dentist visit:
Nutrition: Consumes balanced diet that includes fruits, vegetables, protein, iron rich foods, and < 20 oz 2% milk daily
Elimination: Regular voids and no constipation; toilet trained during day
Sleep: Regular bedtime; sleeps 10 to 13 hours daily
Social history
Activities/childcare during day:
No parental concerns about behavior, temperament
M-CHAT-R/F administered
Developmental milestones
Uses 2-3 word sentences; speech usually understandable
Dresses her/himself and engages in imaginative play
Knows that s/he is a girl/boy
Draws person with 2 body parts
Stands on 1 foot
Walks up stairs with alternating feet
Anticipatory guidance
Screen time < 2 hours daily
Always supervised when outside and/or near water
Firearms in household stored unloaded in firearm safe with ammunition stored separately
General Health
Acute health issues:
Vision/hearing concerns: Refer to ophthalmology/audiology
Oral health
Encouraged twice yearly dental visits
Water source does not contain fluoride: Fluoride drops 0.5 mg/day
Nutrition concerns, low iron intake, and/or consuming > 20 oz milk daily: Obtain CBC
Toilet training: Parents encouraged to visit https://www.healthychildren.org/English/ages-stages/toddler/toilet-training/Pages/default.aspx for more information
Anticipatory guidance: Counseled about appropriate screen time, water safety, car safety, and gun safety
Vaccination/Universal Screening
Vaccination
Live attenuated influenza vaccine
Pt has received < 2 lifetime doses: Administer first dose now followed by 2nd dose in 4 weeks
Pt has received ≥ 2 lifetime doses: Administer 1 dose
All other vaccinations up to date
M-CHAT-RF
0-2: Normal screen
3-7: Positive M-CHAT-R/F responses reviewed; upon clarification
Score < 2: Normal screen
Score remains ≥ 2 with provider concern based on observation: Refer to developmental pediatrics
8-20: Refer to developmental pediatrics
Not achieving developmental milestones:
No previous missed milestones: Reassess in 6 months and refer to early intervention resources and/or medical specialist if issues persist
Persistent developmental delay: Refer to early intervention resources and/or medical specialist
Child may transition to forward-facing car seat when child exceeds weight limit of rear-facing seat
Child should remain in forward facing car seat (not booster seat) until age 5 years
MCHAT scoring
1 point for YES on items on 2, 5, and 12
1 point for NO on all other items
Parental concerns:
General health
No new allergies, medications, health issues
No parental concerns regarding vision, hearing, oral health
Most recent dentist visit:
Nutrition: Consumes balanced diet that includes fruits, vegetables, protein
Elimination: Regular voids and no constipation; toilet training complete
Sleep: Regular bedtime; sleeps 10 to 13 hours daily
Activity: Plays for ≥ 60 minutes daily
Social history
School (plans):
No parent or teacher concerns about behavior, temperament, attention, performance
Developmental milestones
4 Year: Speech usually understandable, engages in fantasy play with peers, knows name/age/gender, names 4 colors, dresses self and brushes own teeth, draws person with 3 body parts, hops on 1 foot
5 Year: Good articulation/language skills, counts to 10, names 4 colors, copies squares/triangles, prints some letters, draws person with 6 body parts, hops on 1 foot
Anticipatory guidance
Screen time < 2 hours daily
Always supervised when outside and/or near water
Always wears helmet
Firearms in household stored unloaded in firearm safe with ammunition stored separately
Acute health issues:
Vision/hearing concerns: Refer to ophthalmology/audiology
Oral health
Encouraged twice yearly dental visits
Water source does not contain fluoride: Fluoride drops 0.5 mg/day
Educated about appropriate nutrition and physical activity
Concerns about attention/school performance: Consider administering Vanderbilt Assessment Scales for ADHD in cases of severe dysfunction
Anticipatory guidance: Counseled about appropriate screen time, water safety, helmet use, car safety, and gun safety
Vaccinations
Administer 4th Polio, 5th DTaP, 2nd MMR, and 2nd varicella if not yet completed
Live attenuated influenza vaccine
Pt has received < 2 lifetime doses: Administer first dose now followed by 2nd dose in 4 weeks
Pt has received ≥ 2 lifetime doses: Administer 1 dose
Not achieving developmental milestones
Has not started school: Refer to early intervention resources and/or medical specialist
Notify school about concerns
Child may transition to forward-facing car seat when child exceeds weight limit of rear-facing seat
Child should remain in forward facing car seat (not booster seat) until age 5 years
ADHD can be diagnosed and treated as young as four years, but there is little evidence to support this practice
Parental concerns:
General health
No new allergies, medications, health issues
No parental concerns regarding vision, hearing, oral health
Most recent dentist visit:
Nutrition: Consumes balanced diet that includes fruits, vegetables, protein
Elimination: Regular voids with limited/no nocturnal enuresis
Sleep: Regular bedtime; sleeps 9 to 12 hours daily
Activity: Plays for ≥ 60 minutes daily
Social history
School/grade:
No parent/teacher concerns regarding behavior, attention, performance
Not a target for
Developmental milestones
6 years: Good articulation/language skills, counts to 10 and can name 4 colors, copies squares/triangles and prints some letters, draws person with 6 body parts, hops on 1 foot
7-8 years: Good peer relationships, interacts well with family, performs chores
Anticipatory guidance
Screen time < 2 hours daily; Internet usage monitored by parents
Always supervised when outside and/or near water
Always wears helmet
Firearms in household stored unloaded in firearm safe with ammunition stored separately
General Health
Acute health issues:
Physical health
Vision/hearing concerns: Refer to ophthalmology/audiology
Oral health
Encouraged twice yearly dental visits
Water source does not contain fluoride: Fluoride drops 1 mg/day
Educated about appropriate nutrition and physical activity
Tanner stage [ ]
No indication of precocious puberty
Parents and patient educated about normal puberty/sexual development
Concerns about attention/school performance: Administer Vanderbilt Assessment Scales for ADHD
Anticipatory guidance: Counseled about appropriate screen time, water safety, helmet use, car safety, and gun safety
Vaccinations
Live attenuated influenza vaccine
Pt has received < 2 lifetime doses: Administer first dose now followed by 2nd dose in 4 weeks
Pt has received ≥ 2 lifetime doses: Administer 1 dose
All other vaccinations up to date
Not achieving developmental milestones: Contact school about concerns