CD JSON Generator

Discipline

: Paediatrics

Sub Discipline

: Pediatric

Document Title

: Paediatrics Clerking Note

Unit

CHIEF COMPLAINT

Chief Complaint

HISTORY OF PRESENT ILLNESS

History Taken From

Present History

PAST HISTORY

Birth History

Medical History

Surgical History

Medication History

Allergy History

ALLERGIES AND ALERT

Allergies

DEVELOPMENTAL HISTORY

Gross Motor

Fine Motor

Vision

Hearing

Speech

Social Skills

School Performance

If There Is Developmental Delay?

YesNo

NUTRITIONAL HISTORY

Nutritional History

IMMUNIZATION

Status

Immunization

FAMILY HISTORY

Family History

SOCIAL HISTORY

Social History

H.E.E.A.D.S.S.S ASSESSMENT

H - Home

E - Education / Employment

E - Exercise

A - Activities

D - Drugs

S - Sexuality

S - Suicidal

S - Spirituality / Safety

PHYSICAL EXAMINATION

Vital Sign

Physical Findings

General Appearance

Cardiovascular System

Respiratory System

Gastrointestinal System

Central Nervous System

Musculo - Skeletal System

Skin

Lymph Nodes

Ent

Eye

Pubertal Status

Other Findings

PROBLEM LIST

Problem List

DIAGNOSIS

Diagnosis

Orders

Others

Referral

Outgoing Referrals

Comments

Plan

DISMISSAL ARRANGEMENT

Follow Up Appointment

Please Update Method

Appointment

SIGNATURES

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