Pediatrics: Follow-up Note Structure and Sections
Paediatric return visit for a known condition. Notermed's built-in Pediatrics: Follow-up Note produces the sections below from what is said during the visit. You read the draft, change anything you want changed, and sign it. Until you sign it, it is a draft and outside the record.
What the Pediatrics: Follow-up Note contains
6 sections, in the order the note puts them, and what each one takes from the visit.
- 1
Interval History
- Course since the last visit
- Response to treatment
- New events or concerns
- 2
Current Symptoms
- Symptoms ongoing or resolved
- Feeding, sleep, and activity
- 3
Medications
- Current medications
- Any changes since the last visit
- 4
Physical Examination
- Vital signs and weight
- Focused examination findings
- 5
Assessment
- Status of the known condition or conditions
- 6
Plan
- Treatment continued or adjusted
- Investigations
- Advice given
- Follow-up interval
A section nobody said anything about is left out of the draft rather than padded. You will not find "not discussed" filling a heading you never covered.
Questions about the Pediatrics: Follow-up Note
What does the pediatric follow-up note contain?
Six sections: Interval History, Current Symptoms, Medications, Physical Examination, Assessment and Plan. The interval history covers the course since the last visit, the response to treatment, and any new events or concerns.
Does it record feeding and sleep?
Current Symptoms does, alongside whether symptoms are ongoing or resolved, and activity. It records what was discussed in the visit and nothing past that.
Is the weight recorded?
The examination section takes vital signs and weight, with focused examination findings. Whatever was measured and said out loud is what appears.
How is the patient data handled while the note is drafted?
Recordings, transcripts and notes are encrypted in transit and at rest. Patient data is stored and processed only on servers in the United States, patient conversations are never used to train AI models, and we sign a Business Associate Agreement with your clinic before any patient data is processed.
What holds true for your patient data
These apply from your first free session, on every plan, whichever format you write in. The technical detail is on the security and HIPAA page.
A BAA first
We sign a Business Associate Agreement with your clinic before any patient data is processed.
US servers only
Patient data is stored and processed only on servers in the United States.
Encrypted throughout
Recordings, transcripts and notes are encrypted in transit and at rest.
Never training data
Patient conversations are never used to train AI models.
Yours to sign
Every note is a draft until the clinician reviews it and signs it.
Structure reviewed
This page describes how a note is structured. It is not clinical guidance, and the clinician who signs the note remains responsible for the record.
See the Pediatrics: Follow-up Note on one of your own visits
Bring a consultation. We will record it, show you the draft in this format, and tell you plainly if Notermed is not a fit yet.