Well-Child Care: Promoting Health and Development
A Chapter in Core Concepts of Pediatrics, 2nd Edition
Amber Hairfield DO and David P. McCormick MD
Pediatricians are in a unique position to contribute to the good health and success of children under their care. A pediatrician often has the opportunity to know the family from the birth of the child and understands the social, medical and developmental factors that can potentially interfere with normal function. The pediatrician can facilitate medical management, provide a referral to a specialist when necessary, work closely with schools and agencies to provide necessary additional services, and initiate community action projects to address important health issues.
It has been said that "the child is not just a small adult." Children differ from grown-ups in both physiology and pathology. They also differ from each other. The health needs of infants, children, and teenagers are not identical.
This chapter will help you learn to:
Familiarize yourself with the electronic medical record (EMR). Look at the Chart Review tab to scan the patient encounters. Be sure to familiarize yourself with the Past Medical History, Social History, Growth Chart, and Medications tabs. Students may update the information in the social history. Students may write a progress note and may enter and 'pend' orders.
During a properly conducted well-child visit, a wide range of medical and social issues need to be addressed. A sample worksheet has been provided to obtain the child and family medical and social history at the first visit for a child of any age. On the left sidebar, there are worksheets specific for each age group.
These worksheets help to ensure that you remember to address issues in the history, physical examination, and social development that are specific to the age group.
Check off organ systems as you examine them and document any abnormal findings. Make a note of any of those systems you are unable to examine, e.g. ear canals that were occluded with wax, or if child was crying so loudly that you could not hear the heart sounds. Use the worksheet to present your findings to your preceptor.
Links on each worksheet will take you to additional information. We recommend that you spend some time exploring each checklist before you examine your first patient.
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NOTE: For patient confidentiality, be sure you shred any temporary documents after you no longer need them. |
Remember that parents appreciate a professional demeanor. If you wear a white jacket, it should be clean. Dress appropriately. No open-toed shoes. No blue jeans. No chewing gum. Be sure your name tag is easily visible, worn on your upper torso near your face, with the photograph showing. Generally, men should wear a tie and women should be certain that their attire is modest.
When you are meeting a new family, always introduce yourself properly and clarify your role in the clinic. For example: "I am Julie Smith, a medical student working in the pediatric clinic this month."
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More Information |
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Cultural Differences: Be sensitive to the fact that life-styles, dietary habits, and the approach to illness may be different in families of different ethnicity and cultural backgrounds. Do not assume that your outlook is necessarily shared by the child's family. If you have a question about a cultural practice with which you are unfamiliar and it relates to the medical care of the patient, please respectfully ask about the cultural practice from a perspective of curiosity, taking care not to come across as judgmental. This helps to better understand family practices and build rapport. If you don't ask, you might miss some important medical information. Alternative or Complementary Medicine: Such therapies are most likely to be used for chronic disease. Ask about this with sensitivity; families will not often volunteer this information. After you take the history of previous medical therapy, a general question such as, "Is there anything else that you have tried for this condition?" may be helpful in eliciting these details. |
Respect the parent's status by using proper titles, "Mr. Smith", "Mrs. Jones", "Dr. Doe". Identify language barriers and use a certified translator when needed. The need for a translator can be anticipated by looking on the top dashboard for "preferred language" and "translator needed: yes/no." The child's siblings should not translate.
As a beginning student, if time and the parent permits, it is a good idea to practice taking a complete history on every patient, even if the patient is not new to the practice. This will help you learn.
Remember to wash your hands or use hand sanitizer in the examining room before and after examining each patient. Excuse yourself and any siblings, if necessary, while the child dons a gown. Infants do not require draping for modesty, but may need partial covering to be kept warm and comfortable.
School age children like to be draped properly during the examination using a gown and sheet/blanket when needed. Be sure you use proper gowning and draping procedures for all children, regardless of age. Shirts and pants should be removed, in order to examine all skin surfaces and so as not to examine to the heart and lungs through clothing, which is not good technique. Leave on the underpants, for modesty, until getting to the genital exam. Proper gowning and draping provide comfort for all. Be sure the child has sufficient privacy when undressing.
Use a calm voice and talk to the parent and child throughout the exam as you perform each step, so there is understanding of what you are doing.
A worksheet follows which will allow you to obtain the child and family's medical and social history at the first visit for a child of any age. A print version is available on the sidebar.
Child and Family Medical History
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Current Health Status |
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Gestation History |
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1. Gravida:_____Para:_____Abortions:_____ |
8. Maternal medications / drugs used during pregnancy 9. Maternal problems during pregnancy: __anemia __hospitalization __syphilis __cardiac disease __hypertension __U.T.I. __diabetes __Rh negative __vaginal bleeding __gonorrhea __rubella __hepatitis __herpes __seizures
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Birth & Nursery Course 12. Place of Birth:_____________________________________________
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Past Medical History |
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Accidents/Illnesses |
Exposures: lead, pesticides, smoke |
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Allergies - "...drug, food, other." |
Hospitalizations |
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Family Medical History |
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___allergies |
___hypertension |
___alcoholism, drug addition |
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___kidney disease |
___hematologic |
___mental illness |
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___cancers |
___neuromuscular |
___incarceration |
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___overweight |
___epilepsy |
___diabetes |
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___hearing problems |
___tuberculosis |
___stroke |
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___other disorders |
____drug/alcohol abuse |
___heart diseases |
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Current Health Status of |
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Mother: |
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Father: |
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Siblings: |
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Medications taken regularly |
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Developmental History |
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Developmental |
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Diet History Diet: see age specific worksheet |
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Social History Who lives at home? Who cares for the baby? Any new changes or stressors at home? Any indoor or outdoor cigarette smoke exposure? Pets? Firearms? Child safety and concern for child abuse? |
In the first year of life, routine visits are scheduled during the first and second weeks of life, and at 2, 4, 6, 9 & 12 months.
The infant's first visit to the office may be as early as 2-3 days of age. Healthy babies are discharged from the nursery after 24 to 48 hours. This is a critical time for establishment of breastfeeding and assessment of problems such as jaundice. If the child is only a few days old, review the physical examination of the newborn and familiarize yourself with some of the common neonatal medical problems before you begin the infant health maintenance exam.
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More Information |
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Complete family medical and social history: Information about the family history can best be obtained by beginning with open-ended questions such as, "Tell me about any medical problems your family members may have had?" You should inquire about the immediate family and grandparents. Extend the pedigree if the family has a history of hereditary diseases, or if other family members play an important role in the child's life. Immunization Record: The basic series of immunizations recommended by United States public health experts can be found here, but many clinics vary the recommended schedule, depending on their sources of funding, whether they have access to new multiple antigen vaccines, and if they are experiencing shortages. Ask your preceptor for a copy of the currently recommended schedule at your clinic site. |
The first visit to the office will require a complete family medical and social history, including family history of illnesses, pregnancy history, and birth history.
Print a current copy of the immunization schedule so you can consult it and learn which immunizations are given when. Recommendations for immunizations change often, so maintain your updates frequently.
Review the Infant Assessment worksheet. We recommend that you spend some time exploring the "Birth to 11 Month Worksheet" and the related information before you examine your first patient.
Infant health maintenance worksheet (birth to 11 months) is available on the sidebar. Click on the highlights below for more detail or to branch to a hyperlink within the popup. You can get to a print version of the form on the side bar.
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Interim History since last well child visit: |
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Concerns to discuss today: OLD CARTS, present history in logical, chronological order |
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Review Past Medical History/Family Medical History (PMH/FMH): Include appropriate information, including dates of hospitalizations/surgeries if possible, ages/illnesses of relatives |
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Medications: Include names, dosages, and frequencies of prescription, over-the-counter, and alternative therapies |
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Allergies: Include drug, food, and environmental allergies and patient's reaction |
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Social History: Include who lives at home, who cares for the baby/daycare, smoke exposure, pets |
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Nutritional Assessment: Breastfeeding ___min every ___hours. Mother's assessment of milk production:_____________ Formula: ___oz every ___hr |
Other foods Vitamins (Fluoride, Iron and Vitamin D) Wet diapers per day Stools per day Parent concerns regarding nutrition or output |
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Mental Health Assessment/Ages and Stages Questionnaire: Include infant crying (Colic), Sleep, family stress, parenting needs, Child abuse risk |
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Developmental Assessment/Ages and Stages Questionnaire: List milestones achieved: gross motor/fine motor/language/personal-social |
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Review of Systems: Vital signs Include Weight_____,______(%), Length_____,______(%), Head circumference _____,______(%), _____,______(%) Temperature_______, Pulse_____,Respiratory Rate________, Blood Pressure (if applicable)____ General appearance Head/Fontanelles Eyes Nose
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Mouth and teeth Oropharynx Neck/Nodes Respiratory Cardiovascular Abdominal Genitalia Musculoskeletal/hips Skin Other |
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Screening: Vision, Hearing, Hemoglobin, Lead questionnaire,Tuberculosis questionnaire, Dental screening/varnish |
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Health Education/Anticipatory Guidance : Nutrition: Formula/Breast, advancing diet, avoid honey, Women Infants and Children (WIC), growth charts Safety: bath, hot water, smoke detectors, Car seats, childproofing, ingestiones, choking, Walkers, falls, sleep position, firearms Health Promotion: immunizations, Tobacco exposure, Med. Resource Use, Minor acute illness, limit screen time, monitor screen content Family: siblings, address concerns |
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Immunizations indicated today: |
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Labs (hemoglobin/lead/other)/procedures (dental varnish) indicated today: Based on screening and Texas Health Steps recommendations |
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Next Well Check : |
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Health maintenance visits are scheduled at 12, 15, and 18 months, 2 years, and yearly thereafter.
The preschool child rapidly develops complex social and neurobehavioral capabilities, and the parents often have questions about the child's behavior and social functioning. Knowledge and experience are needed to differentiate normal variations from abnormal behavior. Use this opportunity to observe normal and abnormal growth and development in preschool children, and observe how experienced pediatricians approach these problems.
If a complete family medical and social history has not previously been obtained, do so now along with the toddler/preschool age health assessment.
Beginning at around 2 years, it is possible for the clinician to have a conversation with the child. But don't try to obtain any useful medical information. The answers you get are likely to be random and make-believe. That doesn't mean you should not communicate- it is a lot of fun and helps to put the child at ease.
By three years of age, children ask lots of questions about the doctor's office and what you are doing. By explaining to the child, you can model good communication skills for the parent and also observe how the parent reacts to the child's behavior. Tell the child what you are going to do. Doctor: "Now I'm going to check your lungs". Child: "What's lungs?" Doctor: "Lungs help you get air". Child: "What's air?" This conversation can go on as long as you like.
A good way to relax the child is to allow him or her to sit on the parent's lap during the exam. Drawing a little smiley face on the end of a tongue blade and playing a game of hide and seek with the face can help distract a nervous child.
Almost all the important organ systems can be examined with the child on the parent's lap. Using your own examination equipment can prevent the need to place the child on the examination table or pulling the cord of the otoscope across the room to where the parent is sitting. A fearful child on the exam table may take two people to hold, but with the child in the lap, the parent can cuddle the child's hands while you examine "difficult" areas such as the throat and ears. Keep talking to relax the child. Don't speak too loudly. Use a comfortable tone of voice. Children are little, but not hard of hearing. Loud voices usually turn them off. Children also like eye contact.
The preschool child health maintenance worksheet, (12 months to 4 years) is available on the sidebar. Click on the highlights below for more detail or to branch to a hyperlink within the popup. You can get to a print version of the form on the side bar.
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Interim History since last well child visit:
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Concerns to discuss today: OLD CARTS, present history in logical, chronological order
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Review Past Medical History/Family Medical History (PMH/FMH): Include appropriate information, including dates of hospitalizations/surgeries if possible, ages/illnesses of relatives
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Medications: Include names, dosages, and frequencies of prescription, over-the-counter, and alternative therapies
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Allergies: Include drug, food, and environmental allergies and patient's reaction
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Social History: Include who lives at home, who cares for the child/daycare, smoke exposure, pets
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Nutritional Assessment:
Breastfeeding ___min every ___hour. milk________oz every _____ hrs (bottle/cups) |
Other liquids (water/juice) Other foods/ Appetite/Schedule Stools per day Parent concerns regarding nutrition or output
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Mental Health Assessment: Include: Tantrums, Behavior challenges, Sleep problems, New family stresses, Parenting needs, Child abuse risk
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Developmental Assessment:/Ages and Stages Questionnaire/MCHAT(18 to 24 months): List milestones achieved: gross motor/fine motor/language/personal-social |
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Review of Systems:
Vital Signs: Weight (percentile):_______,____% BMI: :_______,____% Temperature:_________
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General appearance Oropharynx Cardiovascular Abdominal Genitalia Musculoskeletal/hips Skin Other |
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Screening: Vision, Hearing, Hemoglobin, Tuberculosis questionnaire, Dental screening/varnish,
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Health Education/Anticipatory Guidance: Nutrition: Milk and Juice, Advancing diet, Growth charts Safety: Bath, Hot water temperature, Smoke detectors, Car seats, Childproofing, Ingestions, Choking, Walkers/jumpers, Firearms Health Promotion: Immunizations,Tobacco exposure, Med. Resource Use, Limit screen time, Monitor screen content Family: Siblings, Address concerns |
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Immunizations indicated today: |
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Labs (hemoglobin/lead/other)/procedures (dental varnish) indicated today: Based on screening and Texas Health Steps Recommendations |
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Next Well Check : |
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All children should have a yearly health maintenance visit. By six years of age, most children can provide reasonably accurate medical information, and it is a good idea to talk to the child as well as to the parent.
If this is patient is new to you, obtain the complete family medical and social history. Use the School-Age Child Health Maintenance guide to complete the age-related history and physical examination.
Click on the highlights below for more detail or to branch to a hyperlink within the popup. You can get to a print version of the form on the side bar.
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Interim History since last well child visit:
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Concerns to discuss today: OLD CARTS, present history in logical, chronological order
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Review Past Medical History/Family Medical History (PMH/FMH): Include appropriate information, including dates of hospitalizations/surgeries if possible, ages/illnesses of relatives
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Medications: Include names, dosages, and frequencies of prescription, over-the-counter, and alternative therapies
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Allergies: Include drug, food, and environmental allergies and patient's reaction
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Social History: Include who lives at home, who cares for the child/daycare, smoke exposure, pets
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Nutritional Assessment:
Liquid intake: (water/milk/other such as juice and sugary drinks) |
Snack choices
Urination: Stooling:
Parent concerns regarding nutrition |
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Mental Health Assessment: Include: Sleep, Family stresses, Parenting needs, Child abuse risk, Behavior challenges
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Developmental Assessment:/Ages and Stages Questionnaire: School performances, Extra curricular activities, Communication effectiveness (verbal/written), Interpersonal relationships |
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Review of Systems:
Vital Signs: Weight (percentile):_______,____% BMI: :_______,____% Temperature:_________ |
General appearance Oropharynx Cardiovascular Abdominal Genitalia Musculoskeletal/hips Skin Other |
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Screening: Vision,Hearing, Hemoglobin, Tuberculosis questionnaire, Dental screening
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Health Education/Anticipatory Guidance: Nutritian: Growth charts, Healthy diet Safety: Smoke detectors, Car seats/booster seats, Ingestions, Choking, Stranger safety, Internet safety, Firearms Health Promotion: Immunizations,Tobacco exposure, Med. Resource Use, Limit screen time, Monitor screen content Family: Siblings, Address concerns |
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Immunizations indicated today: |
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Labs (hemoglobin/lipids/other) indicated today: Based on screening and Texas Health Steps recommendations |
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Next Well Check : |
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On average, about half of the visits to a pediatrician's office will be for acute care. Such a visit, differs from a well-child or follow-up visit.
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More Information: Documenting the visit |
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The physician documents the well child visit differently from the acute care visit. Payment is based on the documentation. The amount of documentation depends upon the complexity of the case and the extent of the physical examination necessary to make a diagnosis. A carefully constructed set of guidelines used by all doctors in the United States describes the documentation that is needed for billing acute care visits of differing complexity. As a student, you do not need to know this now, but as a resident, you will have to document at the appropriate level for outpatient visits. For instance, documenting the uncomplicated sick visit (established patient) requires two of the following three key component:
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The typical acute care visit for the sick child only requires a pertinent past and present history, and examination only of the problem-specific organ system(s). In this situation, your preceptor may ask you to take only a brief history and examine only the involved system. Be sure to ask your preceptor if you aren't sure how much history to take and how comprehensive the examination should be.
Acute Otitis Media, David McCormick (Ed)
Immunization Record, CDC
Seats and Seat Belt Protection, American Academy of Pediatrics