Tulane Hospital for Children Pediatric Notes

by Shermini Saini, MD 6/03

Pediatric History and Physical:

Title: “Intern Admit Note” or “Intern H&P”

Date and time

CC: One sentence, preferably “in patient’s or parent’s own words”

HPI:
ROS:
PMH:
Prior hospitalizations. Prior surgeries
Birth History: Full term (FT) vs preterm?
- Normal spont vaginal delivery (NSVD) vs C-section (C/S)? If C/S, why?
- Prenatal care (PNC)?
- Pregnancy complications (e.g. infections (chlamydia, gonorrhea, HIV, hepatitis, herpes, syphilis, Group
B Strep, UTI’s), gestational DM, HTN, pre-E).
- Birth weight (BW)? APGAR score at 1-and 5-minutes?
- Delivery complications?
- Complications in neonatal course? NICU stay? Newborn infections?

Developmental History: Reached all milestones on time, or were there delays?

- Fine motor: holding bottle, drinking from cup, reaching/grabbing, pincer grasp, writing.
- Gross motor: head control, sitting, crawling, standing, walking, running, walking up/down
stairs
- Speech and language: cooing, babbling, “mama/dada”, phrases, sentences,
intelligibility.
PCP? home meds? Medication allergies? immunizations UTD?
Diet? Breast feeding or formula? Which type of formula and how much?

Family Hx: any h/o sickle cell disease, CF, miscarriages, birth defects, childhood malignancies,
asthma, etc.

Social Hx: Where does the family live? Who lives in the household? Smokers? Guns? Pets? Always ask
adolescents about EtOH/tobacco/illicit or IV drug use and if they’re sexually active, do they use barrier protection?
School: What grade are they in? Grades? Behavioral problems? Teacher concerns?

VS: T HR RR BP Pulse ox weight/height/head circumference!! (and plot on growth chart)

PE: General:
HEENT:
Skin:
Neck:
Heart:
Lungs:
Abd:
GU:
neurol:
extrem:
LABS/studies:

Impression: (one sentence summarizing the story, including the most likely diagnosis)

DDx: (list of possible diagnoses, if the diagnosis is not obviously clear)

Plan: By system: or By problem:

CNS: #1
CV: #2
Pulm: #3
FEN/GI: #4
Heme/Onc: etc….
ID:
Social:

Signature
 Tulane Hospital for Children Pediatric Notes
by Shermini Saini, MD 6/03

Pediatric Progress Note: (can use similar format in PICU as well)

Title: “HOI PN” or “Intern Progress Note” (or “HOI PICU PN”)
Date and time

S: Events overnight, based on the check-out you received, new orders in the chart, and patient’s/parent’s self-report.

O: VS, in ranges (lo-hi) and current: T HR RR BP(MABP) weight (is this an incr or decr?)
24hr Ins
24hr Outs: express UOP in cc/kg/hr + # of BM’s

Meds: list all, with dosages and ABx Day #

(Infants: Nutrition: if formula (what type? what rate?)

 calculate total kcals/kg/day over previous 24hrs)

PE: gen:
head:
heart:
lungs:
abd:

Labs / culture results / Xrays / studies:

Assessment: (one sentence summarizing the patient, any changes in their clinical status, their most likely diagnosis, and
what kind of progress they’re making)

Plan: By system (esp in PICU): or By problem:

CNS: #1
CV: #2
Pulm: #3
FEN/GI: #4
Heme/Onc: etc…
ID:
Social:

Signature
 Tulane Hospital for Children Pediatric Notes
by Shermini Saini, MD 6/03

University NICU Progress Note: (Tulane NICU uses preprinted forms, with same information)

Title: “HOI NICU II (or III) Progress Note”

Date and time

S: Events overnight.

O: VS, in ranges (lo-hi) and current: T HR RR BP(MABP) weight (is this an incr or decr?)
24hr Ins: cc/kg/day
24hr Outs: express UOP in cc/kg/hr + # of BM’s

Vent settings: IMV: FiO2 / PIP / PEEP / MAP / rate

or HFOV: FiO2 / P / Hz / MAP

recent CBG, VBG or ABG

Meds: list all, with dosages and ABx Day #

Nutrition: formula (what type? what rate?)

vs. PIA (contains how much dextrose? protein? intralipids (IL)?)
 calculate total kcals/kg/day over previous 24hrs.

PE: gen:
head:
heart:
lungs:
abd:
lines: UVC, UAC, central lines, ETT, foley catheter? Keep track of all devices (a source of infxn).

Labs / culture results / Xrays / studies:

A/P: “____WGA (weeks gestational age), ____PCA (wks post-conceptional age) male/female, DOL # ____…”

In the ICU, plan is always by systems:

CNS:
CV:
Pulm:
FEN/GI:
Heme/ID:
(renal):
(endocrine):

Signature
 Tulane Hospital for Children Pediatric Notes
by Shermini Saini, MD 6/03

Discharge Summary:

Attending / Resident:
Date of admit and discharge!!
Chief Complaint:
Brief History:
Primary D/C diagnosis:
Secondary D/C diagnoses:
Procedures: include dates they were done
Consults:
Complications:
D/C Meds:
Disposition / follow-up:
Diet:
Activity:
Hospital Course: (by systems, if hospital stay was long and complicated)

Off-Service Notes: Must be written on every patients on the ward or in the PICU/NICU at the end of each month. This
note can be organized in any manner you deem appropriate, but should contain the following information:

Brief review of H&P:

Hospital course, by systems: to include review of all major studies and procedures, and discussion of
subspecialty services’ findings. Don’t forget about including social situation and nutritional status.
Plans for each system: to give the oncoming intern and team a complete ‘plan of attack’ for their first day assuming care of
that patient.

X-Cover Addendums: When cross-covering on-call, document in the chart all labs/studies you checked on, as well as all
assessments you personally made on any patients.

“Checking-out / Signing-out”: Always intern-to-intern and resident-to-resident. Should include the following
information:

Brief history – don’t waste too much time giving historical details. If the cross-cover needs to know more, they can
look in the chart.
Updated list of all medications, including dosages and prn meds.
Labs / tests / consults that need to be checked on during the night and what should be done with the results!!
Active issues
Any scary or potentially life-threatening events that could happen during the night and what the plan of action should be in
the event that they occur.

Helpful Pediatric Pocketbooks: all are available at TMC bookstore:

The Harriet Lane Handbook (16th ed). Siberry and Iannone. Approx $43. Also available in PD format (but not yet
very user-friendly) for approx $50.
Pediatrics Recall. McGahren and Wilson. Approx $30.
Clinical Handbook of Pediatrics (2nd ed). Schwartz (editor). Approx $34.
On-Call Pediatrics (2nd ed). Lewis and Nocton. Approx $29.