Tulane Hospital for Children Pediatric Notes



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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.


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