best documentation practices

What Should Be Included in Pediatric Documentation?

Effective documentation should encompass the following key elements:
Patient History: Detailed account of the child's medical, family, and social history.
Growth Measurements: Regular recording of height, weight, and head circumference.
Developmental Milestones: Tracking of age-appropriate developmental progress.
Immunization Records: Up-to-date vaccination status.
Allergies and Medications: Current medications and known allergies.
Physical Examination Findings: Observations from regular and problem-specific exams.
Treatment Plans: Documented care plans, including prescribed medications and follow-up schedules.

Frequently asked queries:

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What Should Be Included in Pediatric Documentation?
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