ASSESSMENT & PLAN · BY PROBLEM
1. Routine infant health examination (Z00.129)
Nine-month check. Weight 19 lb 10 oz (50th centile), length 28.3 in (55th), head circumference 17.7 in (50th). Mother reports good appetite, three solid meals plus breastfeeding.
2. Developmental surveillance
Sits unsupported, pulls to stand, transfers objects hand to hand, babbles non-specifically. No parental concerns raised. Milestones age-appropriate.
3. Immunizations due (Z23)
Third hepatitis B and influenza given today. Lot numbers recorded in the clinic's vaccine field. Next doses at the 12-month visit.
ICD-10 Z00.129 · Z23Protocol: 9-month well-child v1 · all items met