In Pediatrics, the following elements should be meticulously documented: - Patient History: Including prenatal history, birth details, immunizations, and developmental milestones. - Physical Examination: Detailed findings from head to toe. - Diagnostic Tests: Results of lab tests, imaging studies, and other diagnostic procedures. - Treatment Plans: Medications prescribed, dosages, and any other therapeutic interventions. - Follow-Up: Instructions given to parents or caregivers and plans for future visits.
