interacts with other children at school. Lab and/or Diagnostic Tests: (include results or pending) CBC, CMP, Fasting lipids, Lead level and TB skin test – all pending Revised 5/9/18; 8/9/18; 10/29/18
DIAGNOSIS Instructions: 1. Normal well child visit (Z00.129) – are designed for surveillance and screening for children. The American Academy of Pediatrics (AAP) set guidelines for each visit. Surveillance is a procedure for recognizing children at risk for a developmental disorder and involves asking parents if they have concerns about their child’s development. Screening involves use of a standardized tool to clarify identified risk (Hay, Levin, Deterding, & Abzug, 2016). 2. Speech and language delay (F80.4) - limited spoken language and phonetic and word structure repertoires are the selection of appropriate measures for comparison (Davis & Hodge,2017). 3. Final/Primary Diagnosis (es): Normal well child visit (Z00.129) PLAN: Social language and Self-help Enters bathroom and has BM by self Brushes teeth Dresses and undresses without much help Engages in well-developed imaginative play Verbal Language Uses 4-word sentences Uses words that are 100% intelligible to strangers Gross Motor Climb stairs, alternating feet without support Skips on 1 foot Fine Motor Draws a person with at least 3 body parts Draws simple cross Unbuttons and buttons medium-sized buttons Grasps pencil with thumb and fingers instead of fist . Social Determinants of Health Community agencies can help with concerns about your living situation Programs like WIC and SNAP to help with concerns about food Don’t use tobacco/e-cigarettes/alcohol/drugs Ask for help if you are concerned about or have experienced violence from your partner Teach child rules for how to be safe with adults: do not keep secrets, adults should not touch private parts, do not assist the adult with their private parts Maintain or expand participation in community activities School readiness
Give child time to finish sentences, encourage speaking skills by reading/talking together Read together daily; ask child questions about story Children are very sensitive, either easily encouraged or hurt; model respectful behavior and apologize if wrong Provide opportunities for your child to play with other children Visit your child’s preschool/child care program; become actively involved; talk with your child about what they are learning Developing healthy nutrition and personal habits Always have cool water available Provide 16 to 24 oz low-fat/fat-free milk daily Juice is not a necessary drink Offer variety of healthy foods/snacks, especially vegetables, fruits, lean protein Create calm bedtime ritual Media Use Limits on use, promoting physical activity and safe play Limit TV and video to no more than 1 hour a day, no TV in the bedroom, supervise internet use Make opportunities for daily play; be physically active as a family Safety
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- Summer '17
- SOAP Note, speech delay, language delay , Pediatric Soap Note