AI Scribe for Pediatricians

PATIENT: 4-year-old female | DOB redacted | MRN redacted
VISIT TYPE: Well-Child Visit (4 year) — CPT 99392
DATE: April 24, 2026

SUBJECTIVE:
Established patient presenting with mother for routine 4-year well-child visit.
Mother reports child is doing well overall. Eats a varied diet, drinks roughly
16 oz whole milk daily, has 1-2 formed BMs daily, sleeps 10-11 hours nightly
with no parasomnias. Started preschool 4 days/week in September; teacher
reports age-appropriate participation, no behavioral concerns. No injuries
or ER visits since last well visit. No medications. No allergies.

Family History: Maternal grandmother T2DM. Paternal aunt with childhood asthma.
Social: Lives with both parents and 18-month-old sibling. Rear-facing car seat
transitioned to forward-facing 5-point harness at 30 months. Smoke-free home.
No firearms. Helmet use confirmed for tricycle.

Developmental Surveillance (parent report + observed):
- Gross motor: Hops on one foot 3 times, throws overhand, pedals tricycle.
- Fine motor: Copies a cross, draws person with 3 body parts, uses fork.
- Language: 4-5 word sentences, intelligible to strangers ~95%, names 4 colors.
- Social-emotional: Plays cooperatively, separates from parent without distress.
- ASQ-3 administered today: all domains above cutoff. (CPT 96110)

OBJECTIVE:
Vitals:
- Weight: 16.8 kg (50th percentile, CDC)
- Height: 103 cm (50th percentile, CDC)
- BMI: 15.8 (52nd percentile)
- BP: 96/58 mmHg (within normal limits for age/sex/height)
- Temp: 36.8 C, HR 98, RR 22, SpO2 99% RA

General: Well-appearing, well-nourished, interactive, in no distress.
HEENT: AF closed. PERRL. TMs gray, mobile, normal landmarks bilaterally.
Oropharynx clear, dentition without obvious caries, no fluorosis.
Vision screen (HOTV): 20/30 OD, 20/30 OS, 20/30 OU. Pass.
Hearing screen (pure tone, 1/2/4 kHz at 25 dB): Pass bilaterally.
Neck: Supple, no LAD, no thyromegaly.
CV: RRR, no murmur, femoral pulses 2+ symmetric.
Lungs: CTA bilaterally, no wheeze.
Abdomen: Soft, non-tender, no HSM, no masses.
GU: Normal external female genitalia, Tanner 1.
MSK: Full ROM, no scoliosis on Adams forward bend, normal gait.
Neuro: CN II-XII intact, age-appropriate balance and coordination.
Skin: No concerning lesions, no bruising in non-bony areas.

ASSESSMENT:
1. Well 4-year-old female, growth and development appropriate (Z00.129)
2. Up to date on immunizations through 24 month — DTaP #5, IPV #4, MMR #2,
   Varicella #2, and influenza (annual) due today per ACIP 2025-26 schedule.

PLAN:
1. Immunizations administered today (with VIS dates documented and parental
   consent obtained):
   - DTaP-IPV (Kinrix), 0.5 mL IM, R deltoid
   - MMR, 0.5 mL SC, L deltoid
   - Varicella, 0.5 mL SC, L deltoid
   - Influenza inactivated quadrivalent, 0.5 mL IM, R deltoid
   CPT 90460 x 4 (first component, age-appropriate counseling) + 90461 x 4
   (additional components). Vaccine product CPTs reported separately.
2. Anticipatory guidance discussed (Bright Futures): nutrition (5 fruits/veg
   daily, limit juice <4 oz/day), screen time <1 hour/day of high-quality
   programming, sleep hygiene, kindergarten readiness, sun protection, water
   safety / swim lessons, dental visit every 6 months, booster seat use.
3. Vision and hearing screen passed today (CPT 99173 + 92551).
4. ASQ-3 developmental screen normal (CPT 96110).
5. Lead and hemoglobin screening not indicated per current AAP risk-based
   guidance (negative risk factors).
6. Return to clinic in 12 months for 5-year well visit, sooner PRN.
7. After-visit summary in English provided to mother.

Visit Codes: 99392 (preventive, established, age 4), 90460 x4, 90461 x4,
96110, 99173, 92551, Z23, Z00.129.

Time: 25 minutes face-to-face. >50% spent in counseling and anticipatory
guidance.