Dermatology school age sick visit shadow health documentation/ Electronic Health Record
Patient Information: Noah Caputo is a 7-year-old male brought to the clinic by his uncle due to complaints of an itchy rash on his feet and legs.
The patient reports that the rash began last weekend and has been causing itching. He denies any pain, bleeding, or pus related to this dermatological issue during his school-age child health visit.
Pediatric Dermatology: Noah’s Sick Visit
Reason for Seeking Care
Noah’s reason for seeking medical attention is “Rash on lower legs.” The rash is described as red bumps that are pruritic (itchy) and located on both lower legs. He has had no exposure to pets at home but has been around a neighbor’s dog. Scratching the bumps and showering make the itching worse. His uncle tried using a cold compress to relieve the itch and gave Noah children’s diphenhydramine, which provided good relief.
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Medical History
Noah is not currently taking any medications and has no known medication allergies. His medical history shows no ongoing medical issues, and he has never been hospitalized or had surgery.
Social History
Noah enjoys school but reports being bullied. His uncle also mentions that Noah has been stealing at school. He lives with his parents and sometimes stays home alone at night, struggling to prepare meals for himself. The caretaker is unsure if Noah is up to date on his immunizations.
Family History
There is no known family history of skin conditions.
Review of Systems
Noah denies experiencing fever, chills, fatigue, or pain related to his dermatology concerns at this school-age sick visit.
Common Skin Rashes in Children
This visit highlights a common issue: pruritic rashes in children. It’s important for parents to understand the potential causes of these rashes, especially when they appear suddenly.
Sick Visit Documentation and Electronic Health Record Best Practices
Proper sick visit documentation is crucial for effective patient care. Electronic Health Record (EHR) best practices can enhance the quality of care provided to children like Noah, ensuring that all relevant information is captured and easily accessible.
Child Health Assessments and Pediatric Health Maintenance
Routine child health assessments are vital in monitoring growth and development. Pediatric health maintenance ensures that children receive appropriate preventive care, including vaccinations and health education.
Vitals
| Vitals | Current Visit |
|---|---|
| Height | 122 cm |
| Weight | 20.8 kg |
| BMI | 14.3 |
| Temp (<38° C) | 36.2° C |
| HR (60-100) | 78 |
| RR (12-20) | 22 |
| BP | 100/68 |
Documentation / Electronic Health Record
My Provider Notes
| Student Documentation | Model Documentation |
|---|---|
SubjectiveNoah Caputo is a 7-year-old male who is brought to the clinic by his uncle with complaints of an itchy rash in his feet and legs. The patient reports that the rash began last weekend when it started feeling itchy. Denies any pain, bleeding or pus dermatology school age sick visit shadow health documentation. |
Reason for seeking care: “Rash on lower legs.” History of Present Illness: Noah Caputo is a 7 year old male here today accompanied by his uncle who is a non-guardian caretaker with a pruritic rash on his lower legs that his uncle noticed one day ago. Describes rash as red bumps on both lower legs. Does not have any exposure to pets at home, but has had exposure to a neighbor’s dog. States scratching at the bumps and showering make it itch worse. They have not tried any topical treatments for the itching. His uncle did try putting a cold compress on his legs to help relieve the itch. His uncle did give him children’s diphenhydramine with good relief. Family History: No known family history of skin conditions. |
Dermatology Visit for a School-Age Child – Health Record
Electronic Health Records
Data Sheets
Physician’s Notes
Diagnostic Records
Health Indicators
Current Visit Health Data
Height: 122 centimeters
Weight: 20.8 kilograms
Body Mass Index (BMI): 14.3
Temperature (Less than 38°C): 36.2°C
Heart Rate (60-100): 78
Respiratory Rate (12-20): 22
Blood Pressure: 100/68
Electronic Health Records
Physician’s Notes
Student’s Health Records Example Records
Personal Description
Noah Caputo, a 7-year-old boy, is brought to the clinic by his uncle due to complaints of an itchy rash on his feet and legs. According to the patient, the rash began last weekend and has been causing itching. There’s no pain, bleeding, or pus related to this dermatological issue at his school-age sick visit.
Reason for Seeking Medical Attention: “Rash on lower legs.”
History of Current Health Issue: Noah Caputo, a 7-year-old boy, is here today with his uncle, who is not his legal guardian. He has a pruritic rash on his lower legs that his uncle noticed a day ago. The rash is described as red bumps on both lower legs. He has no exposure to pets at home but has been around a neighbor’s dog. Scratching the bumps and taking showers worsen the itching. No topical treatments have been tried. His uncle applied a cold compress to help relieve the itching, and Noah was given children’s diphenhydramine, which provided relief.
Medications: Noah is not currently taking any medications.
Allergies: There are no known medication allergies.
Medical History: Noah doesn’t have any ongoing medical issues and has never been hospitalized or had surgery.
Social History: Noah enjoys school but has experienced bullying. Reports indicate that he has been involved in theft at school. He lives with his parents, stays home alone at night, and struggles to prepare meals. Immunization status is uncertain.
Family History: There is no known family history of skin conditions.
Systemic Review: There are no reports of fever, chills, fatigue, or pain related to dermatology concerns at this school-age sick visit.
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