Tulane Hospital for Children Pediatric Notes

by Shermini Saini, MD 6/03

Pediatric History and Physical:
Title: Intern Admit Note or Intern H&
Date and time
!!: "ne #enten$e, %re&erably in %atient'# or %arent'# o(n (ord#
HI:
)"S:
MH:
rior ho#%itali*ation#+ rior #,r-erie#
.irth Hi#tory: /,ll term 0/T1 2# %reterm3
4 Normal #%ont 2a-inal deli2ery 0NS5D1 2# !4#e$tion 0!/S13 I& !/S, (hy3
4 renatal $are 0N!13
4 re-nan$y $om%li$ation# 0e+-+ in&e$tion# 0$hlamydia, -onorrhea, HI5, he%atiti#, her%e#, #y%hili#, 6ro,%
. Stre%, 7TI'#1, -e#tational DM, HTN, %re481+
4 .irth (ei-ht 0.913 A6A) #$ore at :4and ;4min,te#3
4 Deli2ery $om%li$ation#3
4 !om%li$ation# in neonatal $o,r#e3 NI!7 #tay3 Ne(born in&e$tion#3
De2elo%mental Hi#tory: )ea$hed all mile#tone# on time, or (ere there delay#3
4 /ine motor: holdin- bottle, drin<in- &rom $,%, rea$hin-/-rabbin-, %in$er -ra#%, (ritin-+
4 6ro## motor: head $ontrol, #ittin-, $ra(lin-, #tandin-, (al<in-, r,nnin-, (al<in- ,%/do(n
#tair#
4 S%ee$h and lan-,a-e: $ooin-, babblin-, mama/dada, %hra#e#, #enten$e#,
intelli-ibility+
!3 home med#3 Medi$ation aller-ie#3 imm,ni*ation# 7TD3
Diet3 .rea#t &eedin- or &orm,la3 9hi$h ty%e o& &orm,la and ho( m,$h3
/amily H=: any h/o #i$<le $ell di#ea#e, !/, mi#$arria-e#, birth de&e$t#, $hildhood mali-nan$ie#,
a#thma, et$+
So$ial H=: 9here doe# the &amily li2e3 9ho li2e# in the ho,#ehold3 Smo<er#3 6,n#3 et#3 Always a#<
adole#$ent# abo,t 8t"H/toba$$o/illi$it or I5 dr,- ,#e and i& they're #e=,ally a$ti2e, do they ,#e barrier %rote$tion3
S$hool: 9hat -rade are they in3 6rade#3 .eha2ioral %roblem#3 Tea$her $on$ern#3
5S: T H) )) . ,l#e o= weight/height/head circumference!! (and plot on growth chart)
8: 6eneral:
H88NT:
S<in:
Ne$<:
Heart:
>,n-#:
Abd:
67:
ne,rol:
e=trem:
>A.S/#t,die#:
Im%re##ion: 0one #enten$e #,mmari*in- the #tory, in$l,din- the mo#t li<ely dia-no#i#1
DD=: 0li#t o& %o##ible dia-no#e#, i& the dia-no#i# i# not ob2io,#ly $lear1
lan: .y #y#tem: or .y %roblem:
!NS: ?:
!5: ?@
,lm: ?3
/8N/6I: ?A
Heme/"n$: et$B+
ID:
So$ial:
Si-nat,re
Tulane Hospital for Children Pediatric Notes
by Shermini Saini, MD 6/03
Pediatric Progress Note: 0$an ,#e #imilar &ormat in I!7 a# (ell1
Title: H"I N or Intern ro-re## Note 0or H"I I!7 N1
Date and time
S: 82ent# o2erni-ht, ba#ed on the $he$<4o,t yo, re$ei2ed, ne( order# in the $hart, and %atient'#/%arent'# #el&4re%ort+
O: 5S, in ran-e# 0lo4hi1 and $,rrent: T H) )) .0MA.1 weight (is this an incr or decr?)
@Ahr In#
@Ahr ",t#: e=%re## 7" in $$/<-/hr C ? o& .M'#
Med#: li#t all, (ith do#a-e# and A.= Day ?
0In&ant#: N,trition: i& &orm,la 0(hat ty%e3 (hat rate31
$al$,late total <$al#/<-/day o2er %re2io,# @Ahr#1
8: -en:
head:
heart:
l,n-#:
abd:
>ab# / $,lt,re re#,lt# / Dray# / #t,die#:
Assessment: 0one #enten$e #,mmari*in- the %atient, any $han-e# in their $lini$al #tat,#, their mo#t li<ely dia-no#i#, and
(hat <ind o& %ro-re## they're ma<in-1
Plan: .y #y#tem 0e#% in I!71: or .y %roblem:
!NS: ?:
!5: ?@
,lm: ?3
/8N/6I: ?A
Heme/"n$: et$B
ID:
So$ial:
Si-nat,re
Tulane Hospital for Children Pediatric Notes
by Shermini Saini, MD 6/03
University NICU Progress Note: 0T,lane NI!7 ,#e# %re%rinted &orm#, (ith #ame in&ormation1
Title: H"I NI!7 II 0or III1 ro-re## Note
Date and time
S: 82ent# o2erni-ht+
O: 5S, in ran-e# 0lo4hi1 and $,rrent: T H) )) .0MA.1 weight (is this an incr or decr?)
@Ahr In#: $$/<-/day
@Ahr ",t#: e=%re## 7" in $$/<-/hr C ? o& .M'#
5ent #ettin-#: IM5: /i"@ / I / 88 / MA / rate
or H/"5: /i"@ / / H* / MA
re$ent !.6, 5.6 or A.6
Med#: li#t all, (ith do#a-e# and A.= Day ?
N,trition: &orm,la 0(hat ty%e3 (hat rate31
2#+ IA 0$ontain# ho( m,$h de=tro#e3 %rotein3 intrali%id# 0I>131
$al$,late total <$al#/<-/day o2er %re2io,# @Ahr#+
8: -en:
head:
heart:
l,n-#:
abd:
line#: 75!, 7A!, $entral line#, 8TT, &oley $atheter3 Keep track of all devices (a source of infxn)
>ab# / $,lt,re re#,lt# / Dray# / #t,die#:
AP: !EEEE96A 0(ee<# -e#tational a-e1, EEEE!A 0(<# %o#t4$on$e%tional a-e1 male/&emale, D"> ? EEEEB
In the I!7, %lan i# al(ay# by #y#tem#:
!NS:
!5:
,lm:
/8N/6I:
Heme/ID:
0renal1:
0endo$rine1:
Si-nat,re
Tulane Hospital for Children Pediatric Notes
by Shermini Saini, MD 6/03
"ischarge Summary:
Attendin- / )e#ident:
Date o& admit and di#$har-eFF
!hie& !om%laint:
.rie& Hi#tory:
rimary D/! dia-no#i#:
Se$ondary D/! dia-no#e#:
ro$ed,re#: in$l,de date# they (ere done
!on#,lt#:
!om%li$ation#:
D/! Med#:
Di#%o#ition / &ollo(4,%:
Diet:
A$ti2ity:
Ho#%ital !o,r#e: 0by #y#tem#, i& ho#%ital #tay (a# lon- and $om%li$ated1
Off#Service Notes: !ust be (ritten on e2ery %atient# on the (ard or in the I!7/NI!7 at the end o& ea$h month+ Thi#
note $an be or-ani*ed in any manner yo, deem a%%ro%riate, b,t #ho,ld $ontain the &ollo(in- in&ormation:
.rie& re2ie( o& H&:
Ho#%ital $o,r#e, by #y#tem#: to in$l,de re2ie( o& all maGor #t,die# and %ro$ed,re#, and di#$,##ion o&
#,b#%e$ialty #er2i$e#' &indin-#+ Don't &or-et abo,t in$l,din- #o$ial #it,ation and n,tritional #tat,#+
lan# &or ea$h #y#tem: to -i2e the on$omin- intern and team a $om%lete H%lan o& atta$<' &or their &ir#t day a##,min- $are o&
that %atient+
$#Cover Addendums: 9hen $ro##4$o2erin- on4$all, do$,ment in the $hart all lab#/#t,die# yo, $he$<ed on, a# (ell a# all
a##e##ment# yo, %er#onally made on any %atient#+
! Chec%ing#out Signing#out&: Always intern4to4intern and re#ident4to4re#ident+ Sho,ld in$l,de the &ollo(in-
in&ormation:
"rief hi#tory I don't (a#te too m,$h time -i2in- hi#tori$al detail#+ I& the $ro##4$o2er need# to <no( more, they $an
loo< in the $hart+
7%dated li#t o& all medi$ation#, in$l,din- do#a-e# and %rn med#+
>ab# / te#t# / $on#,lt# that need to be $he$<ed on d,rin- the ni-ht and what should #e done with the results!!
A$ti2e i##,e#
Any #$ary or %otentially li&e4threatenin- e2ent# that $o,ld ha%%en d,rin- the ni-ht and what the plan of action should #e in
the event that they occur
Helpful Pediatric Poc%et'oo%s: all are a2ailable at TM! boo<#tore:
The Harriet >ane Handboo< 0:6
th
ed1+ Siberry and Iannone+ A%%ro= JA3+ Al#o a2ailable in D &ormat 0b,t not yet
2ery ,#er4&riendly1 &or a%%ro= J;0+
ediatri$# )e$all+ M$6ahren and 9il#on+ A%%ro= J30+
!lini$al Handboo< o& ediatri$# 0@
nd
ed1+ S$h(art* 0editor1+ A%%ro= J3A+
"n4!all ediatri$# 0@
nd
ed1+ >e(i# and No$ton+ A%%ro= J@K+