Pediatrics: Well Child Visit Note Structure and Sections
Routine well-child preventive visit. Notermed's built-in Pediatrics: Well Child Visit 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: Well Child Visit Note contains
12 sections, in the order the note puts them, and what each one takes from the visit.
- 1
Visit Type & Age
- Well-child or routine check
- The child age as stated
- 2
Interval History & Parental Concerns
- Concerns raised by the parent or caregiver
- Illnesses or events since the last visit
- How the child has been doing
- 3
Feeding & Nutrition
- Feeding method: breast, formula, solids, table food
- Diet and appetite
- Any supplements
- 4
Elimination
- Bowel and bladder pattern
- Toilet-training status
- 5
Sleep
- Sleep duration and routine
- Sleep concerns raised
- 6
Development & Behaviour
- Milestones the clinician actually reviewed for this child
- By domain: gross motor, fine motor, language, social and emotional
- Behaviour and temperament
- School or childcare
- 7
Past History
- Birth history
- Past medical and surgical history
- Medications and allergies
- Family and social history
- 8
Growth & Vitals
- Weight, length or height, head circumference, BMI
- Percentiles as provided
- Vital signs
- 9
Physical Examination
- Examination findings by system, as stated or dictated
- 10
Screenings
- Developmental, vision, hearing, lead, anaemia, or other screens
- Whether each was performed or ordered
- Results, when given
- 11
Immunizations
- Vaccines given today
- Vaccines explicitly reviewed
- 12
Assessment & Plan
- The overall assessment, plus any concern raised
- Immunizations given
- Anticipatory guidance actually provided
- Screenings or tests ordered
- Referrals
- Return-visit 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: Well Child Visit Note
What does the well child visit note cover?
Twelve sections, from Visit Type and Age through interval history and parental concerns, feeding, elimination, sleep, development, past history, growth and vitals, examination, screenings and immunizations, to the Assessment and Plan.
Does the note add the vaccines that were due?
No. The immunizations section records the vaccines given today and the vaccines that were explicitly reviewed. The draft is built from what was said in the visit, so nothing else joins that list.
Are growth percentiles worked out for me?
No. Growth and Vitals records weight, length or height, head circumference and BMI, with percentiles as they were provided. Notermed reports the numbers it was given rather than calculating new ones.
What happens to a heading the visit never got to?
It is left out of the draft rather than padded, so a short well child check does not come back with empty headings under it.
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: Well Child Visit 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.