in my past med history, i use a short key / template for each [pediatric] patient:

DIAGNOSTIC SUMMARY updated on [date of visit]

CHRONIC HEALTH CONCERNS / PROBLEMS: None

CHRONIC DAILY MEDICATIONS, (To the doctor's best information): None

PRIOR KNOWN SERIOUS ILLNESSES: None

PRIOR KNOWN SERIOUS INJURIES: None

PRIOR KNOWN HOSPITALIZATIONS OVERNIGHT: None

PRIOR KNOWN SURGERIES: None

PRIOR KNOWN ALLERGIES: None

LEARNING / DEVELOPMENTAL CONCERNS: None

OTHER:

ACUTE HEALTH CONCERNS / PROBLEMS / AND DATES SEEN:

Well Child Care: [in this section - each visit is noted- there might be a string of dates like so: 12/15/15; 10/7/15; 8/5/15...etc]
Eating / Feeding problem:
URI:
Strep:
Sinusitis:
Cough:
Congestion:
Rash:
Otitis:
Fever:
Diarrhea:
Constipation:
Gastroenteritis:
GU:
Conjunctivitis:
Injury:
Pain:
Concern:
Asthma:
Viral:

NEED TO REVIEW [i leave 'NEED TO REVIEW' if i do not get a newborn pregnancy history]
~
Pregnancy -
Maternal age when gave birth:
Received prenatal care - Trimester: 1
Gestation: Weeks
Complications pregnancy: No
Complications Labor: No
Delivery: Vaginal
Complications Delivery: No
Birth Weight:
Where Born:
Infant feeding: Breast for: ; then Bottle
During the first year of life: Growth and Development: normal; Serious Illness: no; Overnight Hospitalizations: no; Serious Injuries: no; Received medical specialty care: no; Any General health conditions of concern: no

**********

so as the visits recur- there will be a string of dates attached to acute problems, and serious issues will also be listed.
this is only as good as i remember to do it.
and it is not used for coding identification, but that is formally done in the diagnosis section
this helps me to see in one section most of what i need to know - or at least a good place to start

Richard
Pediatrician
Orlando, FL