The TSWF Pediatric Nursing Services AIM form is intended to be used by nurses and clinical support staff in PCMH clinics for pediatric patients. The form is not designed for use in adult and non-PCMH immunization clinics.

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Pediatrics Nursing Services Recent Changes

  • 21 changes for May-Aug 2018 update
  • Updated obsolete terms to make the form compatible with CORE.
  • UTI Dysuria Procedure
    • Additional clinical clue “AF Dysuria CSSP does not require HCG testing to be performed unless medically indicated”
    • ICD & CPT = ICD-10: R30.0: Dysuria; ICD-10: Z71.89: Other Specified Patient Education; CPT: 81000: Dipstick with microscopy; CPT: 81002: Dipstick without microscopy
    • Added complaint to S/O: Female pt c/o of the following: ” [ ] Dysuria (pain/burning)”
    • Added Exclusion Criteria: Mark ‘Y’ for YES, ‘N’ for NO in the boxes below
      o “[ ] Is one or more UTI symptoms lasting more than 7 days?”
      o “[ ] Pregnant or possibly pregnant?”
      o “[ ] Provider notified of exclusion criteria?”
    • Added to A: Labs to be ordered: ” [ ] N/A”
    • Added to P: “[ ] Provider notified of lab orders/results”
  • Updated Depo-Provera procedure note with revised DEPO-PROVERA procedure note on Meds 2 tab
  • Added blue cue glucose reference ranges.
  • Insulin field route “SQ” changed to Subcutaneous
  • Added CSSRS to Behavioral Health tab
  • Moved PHQ-2 and PHQ9-A to Behavioral Health tab
  • Moved Behavioral Health tab to reside after Screening tab
  • Added the Pediatric reference ranges for POC Glucose (Serum) Testing to the “clinical clue” area of the Fingerstick Glucose Procedure (Procedure Tab 1). Reference: Johns Hopkins Hospital & Branden Engorn, & Jamie Flerlage, (2018) Harriet Lane Pediatric Handbook, 21st Edition.
  • Web Links updated


  • Created December 2015
  • Standardize documentation
  • Intended use in PCMH clinics for pediatric patients

The TSWF Pediatric Nursing Services form was created in late 2015 and went live on the AHLTA Enterprise in September 2016. It was created to standardize the nursing services documentation of administered immunizations, medications, nursing procedures, and patient education/counseling performed at the point-of-service. The form’s intended use is acute, routine, or other scheduled visits to PCMH clinics for Pediatric patients 0 months to 17 years of age.

Form Lead

TSWF-Pediatrics Nursing Services Form Lead
Scot Ario

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