Peds Emerg Note - Updated December 2024

Chief Complaint

[Pediatric intake, e.g., well-child check, first visit, chronic cough]

History of Present Illness

[Document the details surrounding the child’s chief complaint. Include onset, duration, frequency, severity, and any associated symptoms. Describe the parent’s account of the current issues they are having in relation to the chief complaint and any concerns or expectations they express.]

Past Medical History

[Include all significant medical conditions with dates if available, hospitalizations, major illnesses, surgeries, and any chronic conditions. List these in bullet form. Family history: [Include if mentioned: significant medical conditions in first-degree relatives, e.g., diabetes, hypertension, heart disease, genetic disorders. Pregnancy History: [Include if mentioned: Details about the pregnancy and birth of the child, including gestational age at birth, any pregnancy or birth complications, type of delivery, birth weight and length, APGAR scores Nutritional history: [Include if mentioned, Details about breastfeeding or formula feeding, introduction of solid foods, current diet] Developmental history: [Include if mentioned. Developmental milestones (e.g., motor skills, language development), any developmental delays or concerns]

Immunizations

[Document the child’s immunization status, including dates of all received vaccinations]

Current Medications

[Include the name, dosage, frequency, and route of administration for all current medications, including over-the-counter drugs and supplements]

Social History

[Include information on tobacco exposure, household environment, pets, caregivers, childcare, and any relevant social factors For older children and adolescents, include information on school performance, peer relationships, sexual activity, high risk behaviors, substance use, and any mental health concerns]

The Review of Systems

[Document a system-by-system review of symptoms the patient is experiencing, Include all pertinent positives and negatives. Do NOT repeat symptoms that are described in the History of Present Illness. Do NOT include physical exam findings. Do NOT create symptoms that were not discussed.]

Vital Signs

[Include blood pressure, heart rate, respiratory rate, temperature, weight, height, BMI, head circumference if applicable. If not mentioned, document "vital signs as per electronic triage".]

Physical Examination

General – Appears well, no obvious discomfort Eyes – [, no discharge, sclera white, conjunctiva pink] ENT – [PERRL with number of mm stated, no conjunctival pallor, No cervical lymphadenopathy, TMs normal, normal oropharynx normal with no erythema or exudates, neck supple, document any stated abnormalities] Respiratory – [Lungs clear to auscultation bilaterally with no wheezes or crackles, normal symmetrical chest expansion, no increased WOB. Document any abnormalities stated] Cardiovascular – [Heart rate regular, S1S2 normal with no murmurs or added sounds, capillary refill duration as stated, central or peripheral cyanosis if described, no peripheral edema] Abdomen – [abdomen soft and non-tender, no distension, no hepatosplenomegaly. Document any abnormalities described] Musculoskeletal – [No tender, swollen, warm, or erythematous joints. Normal range of motion in examined limbs, no muscle tenderness] Neurological – [Alert and oriented in time, space, and person, normal gait, strength 5/5 in upper and lower limbs, CN 2-12 grossly intact, coordination intact] Skin – [No rashes, including to palms and soles. Document any skin abnormalities described.]

Investigations

[Include any planned investigations as described. If none mentioned, state "no laboratory or imaging investigations required at this time."]

Problem

[List problems/diagnoses identified]

Differential Diagnosis

[If relevant, include potential alternative diagnoses relevant to the clinical presentation]

Plan

Orders and Referrals: [Include laboratory tests, imaging studies, referrals to specialists if needed] Treatments: [Include medications prescribed, non-pharmacological treatments, and other interventions] Patient Education: [Discuss educational points provided to the patient’s caregivers, such as lifestyle modifications, disease-specific information] Follow Up: [Include follow-up appointments, monitoring plans]

Plan

Orders and Referrals: [Include laboratory tests, imaging studies, referrals to specialists if needed] Treatments: [Include medications prescribed, non-pharmacological treatments, and other interventions] Patient Education: [Discuss educational points provided to the patient’s caregivers, such as lifestyle modifications, disease-specific information] Follow Up: [Include follow-up appointments, monitoring plans]