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Pediatric History and Physical Write-Up

Please do this on an infant with conjunctivitis
Pediatric History and Physical Write-Up
Students are required to do a full history and physical write up for patients encountered during practicum. A write-up must be conducted for (1) pediatric patient chosen from each of the following age groups: Infant, Toddler, Preschooler, School Age or Adolescent. These write-ups should include a complete history and physical, along with differential diagnosis, plan of care, billing codes, medications prescribed, etc. Each H&P should be submitted to a separate drop box with a file name indicating the age group examined for the submitted H&P. Example: Wallace HandP Toddler.docx. There is a sample H&P that students are welcome to use for formatting available in the resources section of Canvas. In addition, see the rubric on pages 9-11 of syllabus.

Pediatric History and Physical Rubric
Required Element Points Available Comments Points Earned
Content. H&P should include ALL of the following content areas (see sample H&P posted to Canvas). 90 (see points breakdown of each section below)
-          Provider information and date of service
-          Patient information (initials, age, race/ethnicity, insurance)
-          Allergies
-          Medications
-          Chief Complaint
-          Historian (patient, parent,etc.)
-          History of Present Illness (4 points)
Past Medical History
-          Birth History (Prenatal, Natal, Postnatal)
-          Medical/Surgical History
-          Injuries
-          Hospitalizations
-          Family Medical History (2 generations- parents and grandparents)
-          Social History
-          Immunizations
-          Restate any allergies and current medications in this section as well
-          Herbal/Vitamins/Alternative Supplements/Treatments
-          Lead exposure?
-          TB exposure? (5 points)
ADL’s and Habits
-          Diet
-          Elimination
-          Sleep
-          Activity
-          Oral Health
-          Safety/Risk Assessment (age appropriate) (4 points)
Growth and Development
-          Physical Growth (include a growth chart as appendix)
-          Motor
-          Cognitive
-          Verbal
-          Social
-          Personality
-          School (10 points)
Review of Systems
-          Constitutional
-          Skin
-          Neurological (include sensory)
-          HEENT
-          Oral/Teeth
-          Cardiovascular
-          Respiratory
-          GI
-          GU
-          Reproductive
-          Musculoskeletal
-          Endocrine
-          Infectious Disease
-          Psychological/Mental
-          Developmental (15 points)
Physical Exam
-          Weight
-          Height
-          BMI
-          Vital Signs
-          General
-          Mental status
-          Neuro (include cranial nerves checked, reflexes, sensory and motor)
-          Emotional/Psychological
-          Skin
-          Hair/Nails
-          Neck
-          Lymph nodes
-          Head
-          Eyes
-          Ears
-          Nose
-          Throat
-          Mouth/Teeth
-          Cardiovascular
-          Pulmonary/Thorax
-          Chest
-          Abdomen
-          Genitourinary
-          Rectum/Anus
-          Musculoskeletal
-          Extremities
-          Joints
-          Back (15 points)
Stages of Development
-          Erickson
-          Piaget
• Include explanation of WHY this patient is in the identified stage of development AND if it is developmentally appropriate for their age group.
-          Motor sensory development
-          Overall developmental assessment (Is this patient’s development appropriate for their chronological age?) (5 points)
Overall Impression of Assessment
- (5 points)
Presumptive Diagnoses (include codes) (5 points)
Differential Diagnoses (at least 5) (5 points)
Plan with Evidence-based rationale (include references) (10 points)
Billing Codes (include both ICD and CPT codes) (7 points)
APA format, correct spelling and grammar. Paper should include title page, appropriate headers and headings, in-text citations as appropriate, and reference page. 10 points





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