What components should be included in a primary care note for a 15-year-old female adolescent?

From the Guidelines

A primary care note for a 15-year-old girl should include comprehensive documentation of her current health status, developmental stage, and preventive care needs, as recommended by the American Academy of Pediatrics guidelines 1. The note should begin with chief complaint and reason for visit, followed by a detailed history including medical, surgical, family, social, and menstrual history.

• Document vital signs (height, weight, BMI, blood pressure, pulse, temperature)
• Growth chart plotting
• Physical examination findings
• Include an assessment of pubertal development using Tanner staging, as suggested by the American Academy of Pediatrics 1
• Address psychosocial aspects through HEADSS assessment (Home, Education, Activities, Drugs, Sexuality, Suicide/depression, Safety)
• Document immunization status, particularly HPV vaccination if not completed
• Include screening for depression, anxiety, eating disorders, and risk behaviors, as recommended by the policy statement on the future of pediatrics: mental health competencies for pediatric primary care 1
• Note any preventive counseling provided regarding nutrition, physical activity, screen time, sleep, substance use, and sexual health
• Document the assessment, diagnosis, treatment plan, and follow-up recommendations This comprehensive approach ensures appropriate care during adolescence, a critical developmental period with unique physical and psychosocial needs that require confidential, developmentally appropriate care while still involving parents appropriately.

From the Research

Primary Care Note for a 15-Year-Old Girl

The primary care note for a 15-year-old girl should include:

• A complete history that addresses any concerns from the patient and family, and screens for lifestyle habits, including:
  • Diet
  • Physical activity
  • Daily screen time
  • Hours of sleep per night
  • Dental care
  • Safety habits
  • School performance, which can be used for developmental surveillance 2
• A full physical examination to detect any signs of disease or injury, including:
  • Screening for obesity, defined as a body mass index at or above the 95th percentile for age and sex
  • Checking blood pressure annually, starting at three years of age
  • Vision and hearing screening annually or every two years
  • Screening for scoliosis and testicular examination are not routinely recommended 2, 3
• Immunizations and screenings, including:
  • Age-appropriate immunizations
  • Catch-up immunizations
  • Screening for hypertension, vision and hearing problems, and dyslipidemia, as recommended by the American Academy of Pediatrics 2, 3
• Additional considerations, such as:
  • Providing resources for comprehensive, intensive behavioral interventions for children with obesity
  • Recommending at least 400 IU of vitamin D daily, with higher doses indicated in children with vitamin D deficiency
  • Providing daily fluoride supplements for children living in areas with inadequate levels of fluoride in the water supply (0.6 ppm or less) 2, 3

Mental Health and Wellbeing

The primary care note should also consider the patient's mental health and wellbeing, including:

• Screening for anxiety and depression, although there is insufficient evidence to recommend routine screening for depression before 12 years of age 2, 3
• Assessing the patient's awareness of human papillomavirus (HPV) and its implications, as well as their health-related quality of life, anxiety, and depression symptoms 4, 5