Tài liệu Practice Guidelines 2013 Pediatric Well Child Care Flow Sheets ppt

Sleep position Regards face Head Abdomen Babysitters Follows to midline Responds to sound Fontanelle Eyes Umbilic Genitalia Pet control Secondary tobacco smoke Red Reflex Testes Tap

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Practice Guidelines

2013 Pediatric Well Child Care Flow Sheets

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P HYSICIAN G UIDELINES FOR P REVENTIVE S ERVICES

Capital BlueCross’ Physician Guidelines for Preventive Services should serve as a useful component of your delivery of preventive services We urge you to refer to them frequently and aim for the highest compliance possible Additional suggestions follow:

 Make preventive services one of your practice’s highest priorities

 Consider every visit as an opportunity to promote wellness services

 If time and resources are especially scarce, try devoting attention to at least a few key areas on a seasonal basis

 Post a copy of the Guidelines in each consultation/exam room

 Reinforce our efforts to educate Members about the importance of health

maintenance interventions

 Use office reminder systems, including wall posters and chart alerts

 Involve non-physician staff in the process, including the delegation of specific

responsibilities

The Guidelines include:

Adult Health Maintenance Guidelines (Commercial)

Adult Health Maintenance Guidelines (SeniorBlue and SeniorBlue PPO)

Child Health Maintenance Guidelines

Pediatric Well Child Care Flow Sheets

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DEVELOPMENTAL TASKS PRESENT

NORMAL ABNORMAL

ANTICIPATORY GUIDANCE AND

SAFETY

Palmar grasp General Appearance Formula Crib safety Date of Visit Raises head when prone Skin Fem Art Sleep position

Regards face Head Abdomen Babysitters Follows to midline

Responds to sound

Fontanelle Eyes

Umbilic Genitalia

Pet control Secondary tobacco smoke Red Reflex Testes Tap water not to exceed 120F Follow-up on abnormal ENT Extrem for bathing

Newborn Screens Lungs Hips Smoke detectors

Heart Neuro Vitamins (breast-fed babies)

Coughs/colds Urine

Return _

Provider Initials

SAFETY

Palmar grasp General Appearance Formula Crib safety Date of Visit Raises head when prone Skin Fem Art Sleep position

Regards face Head Abdomen Babysitters Follows to midline

Responds to sound

Fontanelle Eyes

Umbilic Genitalia

Pet control Secondary tobacco smoke Red Reflex Testes Tap water not to exceed 120F ENT Extrem for bathing

Lungs Hips Smoke detectors Heart Neuro Coughs/colds

Urine Immunizations:

Return _

Provider Initials

SAFETY

when held upright General Appearance Formula Daycare / babysitters

Date of Visit Regards face in direct line Skin Fem Art Sleep position

of vision

Grasps rattle placed in hand

Head Fontanelle Eyes

Abdomen Genitalia Testes

Fall prevention Coughs/colds Social smile

Coos

ENT Lungs

Extrem Hips Responds to sound Heart Neuro

Immunizations:

Urine

Return _

Provider Initials

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P EDIATRIC W ELL C HILD C ARE

2/94; REV.:1/97;3/98,3/99,5/02,4/04,6/05,3/08,4/09,3/10,4/12 T:\QM\TRANSFER\FORMS\PED CHART REVISED 6-05.DOC LAST PRINTED 5/30/20122:03:00PM

Health care benefit programs issued or administered by Capital BlueCross and/or its subsidiaries, Capital Advantage Insurance Company® and Keystone Health Plan® Central Independent licensees of the Blue Cross and Blue Shield Association Communications issued by Capital BlueCross in its capacity as administrator

SAFETY

Raises body on hands General Appearance Formula Reinforce falls prevention Date of Visit when prone Skin Heart Avoid small objects

Rolls prone to supine Plays with hands Follows parent with eyes

Eyes Head Fontanelle

Fem Art

Abdomen Genitalia

Coughs/colds

Smiles, coos, laughs, squeals, gurgles

ENT Lungs

Extrem Hips

Cereal Neuro

Immunizations:

Return _

Provider Initials

DEVELOPMENTAL TASKS

PRESENT

SAFETY

Passes hand to hand General Appearance Formula Check home for hazards Date of Visit Rolls over Head Heart hot liquids, electrical outlets,

Reaches for toys Bears weight Raking hand pattern Babbles, laughs

Fontanelle Skin EOM ENT

Fem Art

Abdomen Genitalia Extrem

poisons, medicines, dangling cords or table covers Provide Poison Control phone # Turns to voice Eyes

Teeth

Hips Neuro

Puréed foods (including

Sleep position Sun exposure Lungs iron sources) Crib safety

Fluoride Car restraints

Coughs/colds

Return _

Provider Initials

SAFETY

Crawls, creeps General Appearance Formula Avoid popcorn, nuts, raw carrot Date of Visit Pulls to stand Head Heart Table Food or celery sticks, raw apple, raisins

Assisted walking Inferior pincer grasps - pokes

Fontanelle Skin ENT

Abdomen Genitalia Neuro

or tiny pieces of toys Family/social dynamics Sun exposure

Bangs two toys together Pat-a-cake

Peek-a-boo Imitates speech sounds “Dada” Mama”

Eyes Teeth Lungs

Extrem Hips

Self-feeding Toast Teething bisc

Wean to cup Fluoride

Tooth care Car restraints Coughs/colds

Immunizations:

Return _

Provider Initials

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SAFETY

Walks w/support or few General Appearance Milk stair safety, water safety, auto seat Date of Visit steps alone Head Heart (whole milk) restraints; fences and gates

Precise pincer grasp Points

Has 1-3 new words plus

Fontanelle Skin ENT

Abdomen Genitalia Extrem

Table foods Continue weaning

Tooth care Sun exposure Coughs/colds “Dada” “Mama”

Looks for dropped or hidden objects

Eyes Teeth Lungs

Hips Neuro

to cup

MVI Immunizations:

Return _

Provider Initials

ANTICIPATORY GUIDANCE AND SAFETY

Crawls up stairs Puts raisin in bottle

General Appearance Skin Fem Art

Toothcare

No bottle in

Home/environment safety Socialization

Date of Visit Points to 1-2 body parts Eyes Abdomen bed Tantrums/behavior

Gestures Understands simple commands

Head Fontanelle ENT

Genitalia Testes Extrem

Finger foods Fluoride

Sun exposure Coughs/colds Uses cup Teeth

Lungs

Gait Neuro

MVI

Return _

Provider Initials

18 Months Walks up stairs with help Length Wt HC Mealtime not STRESS FIRMLY:

Sits in a chair General Appearance to be a battle Stairs & window safety Date of Visit 3-4 Cube tower

Uses spoon

Head Fontanelle

Abdomen Genitalia

Discourage snacks

Avoid playing in street/driveway Coughs/colds

Imitates a crayon stroke 4-10 words

May tell 2 or more wants

Skin Eyes ENT

Testes Extrem Gait

Toothcare Fluoride

Don’t leave alone in car or home Guard against falls, electrical injuries, drowning

Knows body parts Autism screening

Teeth Lungs

Neuro MVI Sleep patterns & night fears

Toothbrushing

Return _

Provider Initials

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Jumps in place Sits in a chair

General BMI Skin Lungs

Over eating

No snacks

from windows, cabinets, furniture; eat and drink when sitting; poison Date of Visit 5-6 Cube tower Eyes Heart Fluoride danger; avoid machinery, plastic

Makes horizontal or circular strokes

50+ Words Knows name

Head ENT Hearing Vision

Abdomen Genitalia Extrem Neuro

MVI bags

Read to child Toilet training Sun exposure “What’s that?”

Parents understand child’s

Teeth Poison control information

Coughs/colds speech

Return _

Provider Initials

Jumps in place Sits in a chair

General BMI Skin Lungs

Over eating

No snacks

from windows, cabinets, furniture; eat and drink when sitting; poison Date of Visit 5-6 Cube tower Eyes Heart Fluoride danger; avoid machinery, plastic

Makes horizontal or circular strokes

50+ Words Knows name

Head ENT Hearing Vision

Abdomen Genitalia Extrem Neuro

MVI bags

Read to child Toilet training Sun exposure “What’s that?”

Parents understand child’s

Teeth Poison control information

Coughs/colds speech

Return _

Provider Initials

Pedals tricycle Opens door

General BMI Skin Teeth

drinks & food Feeds self

Knives out of reach Stay out of streets Date of Visit 9 Cube tower Head Lungs entirely Water safety

Copies circle Does some dressing Feeds self

Eyes ENT EOM

Heart Abdomen Back

Read to child Speech or language evaluation Sun exposure

Knows full name, age, sex Counts to three

Comprehends “tired, “cold,” “hungry”

Vision test Genitalia

Extrem Neuro

Dental care &

referral Fluoride

Coughs/colds

Immunizations:

MVI

Return _

Provider Initials

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Climbs ladder Can cut & paste

mealtimes Offer small

street crossing and/or play; booster seat, and/or appropriate Date of Visit Knows 3 or 4 colors Head Lungs portions seat belt placement; avoid

Dresses & undresses w/supervision

Counts to 10 Gender ID

Eyes EOM ENT Vision test

Heart Abdomen Back Neuro

Seconds available

strangers; home fire safety;

sleep in own bed Sun exposure Marble & card games; bed time Draws person - 3 parts

Copies cross, circle &

maybe square

Genitalia Extrem

Dental care Fluoride

ritual; nursery school, daycare, babysitting

Car booster seat MVI Bike helmet

Coughs/colds

Immunizations:

Return _

Provider Initials

Dresses & undresses self Can throw and catch a

Street sense School experiences/readiness Date of Visit bean bag Head Lungs Separates from parents

Gallops, begins skipping, alterntaing feet

Prints some letters and numbers

Eyes EOM ENT

Heart Abdomen Back Neuro

Family dynamics Bike helmet Car booster seat Sun exposure

Vision test

Genitalia Extrem

Dental care Fluoride Hearing test MVI

Immunizations:

Return _

Provider Initials

PRESENT

Laces and ties shoes Growing capacity for self-

Monitor snacks

Home environment School environment Date of Visit regulation of behavior Head Lungs Car booster seat

Can answer phone, take simple messages

School experiences

Eyes EOM ENT

Heart Abdom Back

Sun exposure Firearm safety Exercise Vision test

Genit Extrem

Dental care Fluoride Hearing test Neuro MVI Immunizations:

Return _

Provider Initials

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PRESENT

Laces and ties shoes Growing capacity for self-

Monitor snacks

Home environment School environment Date of Visit regulation of behavior Head Lungs Car booster seat

Can answer phone, take simple messages

School experiences

Eyes EOM ENT

Heart Abdom Back

Sun exposure Firearm safety Exercise Vision test

Genit Extrem

Dental care Fluoride Hearing test Neuro MVI Immunizations:

Return _

Provider Initials

PRESENT

8 Years Physical/skills develop Ht Wt BP Balanced diet Illicit drugs/alcohol/tobacco

Emotional development Intellectual development

General BMI Skin Genitalia

Monitor snacks

Home environment Puberty

Date of Visit Social development HEENT Extrem Exercise

Community Interests

Teeth Nodes Chest

Back Neuro

Peer pressure Family dynamics Seat belt placement Heart

Abdomen

Vision test Dental care

Fluoride

Sun exposure Firearm safety

Return _

Provider Initials

PRESENT

Monitor snacks

Community Interests

Teeth Nodes Chest

Back Neuro

Abdomen

Vision test Dental care

Fluoride

Return _

Provider Initials

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PRESENT

Monitor snacks

Community Interests

Teeth Nodes Chest

Back Neuro

Abdomen Vision test

Return _

Provider Initials

PRESENT

Monitor snacks

Community Interests

Teeth Nodes Chest

Back Neuro

Abdomen Vision

test

Return _

Provider Initials

PRESENT

Monitor snacks

Community Interests

Teeth Nodes Chest

Back Neuro

Abdomen Vision

test

Return _

Provider Initials

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PRESENT

Monitor snacks

Community Interests

Teeth Nodes Chest

Back Neuro

Abdomen

Vision test

Return _

Provider Initials

PRESENT

14 Years Physical/skills develop Ht Wt BP Cholesterol Illicit drugs/alcohol/tobacco

Emotional development Education

General Skin

BMI Extrem

Exercise Injury prevention; firearms Date of Visit Social relationships HEENT Back MVI Nutrition

Teeth Nodes Chest

Genitalia Neuro

Pregnancy prevention Sexually transmitted diseases TSE/BSE

Heart Abdomen

Vision test

Dental care Sun exposure

Chlamydia/STD screening Pelvic exam Pap Immunizations:

Return _

Provider Initials

PRESENT

15 Years Physical/skills develop Ht Wt BP Cholesterol Illicit drugs/alcohol/tobacco

Emotional development Education

General Skin

BMI Extrem

evaluation Exercise

Injury prevention; firearms Date of Visit Social relationships HEENT Back MVI Nutrition

Teeth Nodes Chest

Genitalia Neuro

Pregnancy prevention Sexually transmitted diseases TSE/BSE

Heart Abdomen

Vision test

Dental care Sun exposure

Chlamydia/STD screening Pelvic exam Pap Immunizations:

Return _

Provider Initials

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