What should be documented during a pediatric physical examination for a child with a history of previous illnesses, allergies, and pre-existing medical conditions?

Documentation for a Child's Physical Examination

A comprehensive pediatric physical examination should document demographic information, complete medical/developmental/social history, thorough physical findings with growth parameters, the child's cooperation level, and condition-specific assessments tailored to the child's age and presenting concerns.

Essential History Components

Demographic and Background Information

• Document sex, date of birth, identity of parent/caregiver, relationship of historian to patient, and other pertinent healthcare providers 1
• Record chief complaint with specific details about onset, frequency, and associated symptoms 1
• Note any language barriers that may affect communication 1

Comprehensive Medical History

• Birth history including gestational age, birth weight, and pertinent prenatal/perinatal factors (maternal alcohol, tobacco, or drug use during pregnancy) 1
• Previous illnesses, injuries, hospitalizations, emergency room visits, and surgeries 1, 2
• Current and recently adjusted medications, over-the-counter medications, complementary/alternative treatments, and documented allergies 1, 2
• Past medical problems and treatments, including eyeglasses or other therapeutic interventions 1

Developmental and Educational Assessment

• Developmental history and milestones, including presence of any developmental delays 1, 3
• School performance, grade level, academic strengths/challenges, attention span, and ability to complete tasks 1, 2
• Learning difficulties or behavior problems 1, 2

Family and Social History

• Family history of relevant conditions (strabismus, amblyopia, genetic diseases, diabetes, cardiovascular disease, mental illness, substance abuse) 1, 4
• Family composition, who lives in the home, and recent changes in family structure 2, 4
• Social history including social interactions, friendships, difficulties with peers, and issues with social interactions 1, 2
• Family stressors (financial concerns, housing stability, family conflicts) 2
• Screening for exposure to violence, substance abuse, or mental illness in the home 2, 4

Nutrition and Lifestyle

• Diet and nutrition patterns, including typical meals, snacks, food preferences, allergies/intolerances, and nutritional supplements 2
• Sleep patterns, bedtime routines, sleep duration, difficulties falling/staying asleep, snoring, or bedwetting 2
• Screen time habits (television, computer, video games, mobile devices) 2

Safety Assessment

• Home safety measures (smoke detectors, carbon monoxide detectors, gun safety) 2
• Car safety and consistent use of appropriate restraints 2
• Helmet use during activities 2
• Exposure to environmental hazards (lead, mold, secondhand smoke) 2
• Internet safety practices and parental monitoring 2

Physical Examination Documentation

General Assessment

• Document the child's level of cooperation with the examination, as this is useful for interpreting results and making comparisons over time 1
• Vital signs including heart rate, respiratory rate, and blood pressure 1, 4
• Growth parameters plotted on appropriate growth charts (height, weight, BMI) 4, 5

Systematic Physical Findings

• General appearance and any dysmorphology or asymmetry 1
• Skin examination 4
• HEENT (head, eyes, ears, nose, throat) examination 4
• Cardiovascular and respiratory examination 4
• Abdominal examination 4
• Musculoskeletal examination 4
• Neurological examination 4
• Pubertal development assessment (Tanner staging) when age-appropriate 4, 3

Condition-Specific Documentation

For children with chronic conditions, document specific symptom management, medication adherence, and impact on daily activities 2

When relevant based on presenting concerns or age:

• Visual acuity testing and binocular red reflex (Brückner) test 1
• Developmental screening results using standardized tools 2, 5
• Mental health screening using age-appropriate tools (Pediatric Symptom Checklist, Strengths and Difficulties Questionnaire) 2
• Immunization status and updates 1, 3, 5

Critical Documentation Elements for Children with Pre-existing Conditions

Medical Baseline Establishment

• Height, weight, and baseline laboratory values before initiating medications with known risks 1
• Neutrophil and lymphocyte counts, C-reactive protein 1
• Condition-specific laboratory monitoring 1

Review of Systems

• Pertinent review of systems including history of head trauma and relevant systemic diseases 1
• Physical symptoms or concerns (headaches, stomachaches, fatigue) 2
• Urinary symptoms if history of urinary tract infections 1

Common Documentation Pitfalls to Avoid

Incomplete vital signs documentation is particularly problematic in younger children, with documentation rates as low as 30.8% in infants under 1 month 6. Ensure complete vital signs are obtained and recorded for all age groups.

Half or more of records commonly omit: witnesses to injury, past injuries, detailed description of injury size/color, illustrations, developmental history, and genital examination when indicated 7. These elements must be systematically addressed.

For adolescents, failing to provide confidential screening time results in missed opportunities for identifying psychosocial risks, sexual health concerns, and mental health issues 4.