GUIDE LINES FOR RESIDENT’S ON LINE PATIENT DOCUMANTATION IN THE PICU
TEMPLATE SECTION
1. Resident:
2. Admitted:
3. D/C Date:
4. CC:
PICU DISCHARGE SUMMARY GUIDELINES
Pediatric D/C Summary Note
August 16, 2007
IMFORMATION /DOCUMENTAION GUIDE
auto entry with key.
date auto entry.
date auto entry
Same as admitting history
Word document - use the following guidelines,
SUMMARIZE INFORMATION.
USC / PMD
5. Hospital Course:
Age, sex, ethnicity.... mention reason for admission to PICU
a. Hospitalization #..and: (this is his/hers first hospitalization)
b. Previous health condition (base line), if any chronic illness and
The reason for admission.
Examples
i. 6 yo Hispanic female Previous healthy, First
hospitalization admitted because severe respiratory
distress 2nd RSV + bronchiolitis, OR
ii. 15 yo AA male Known to have severe persistent
asthma admitted in severe respiratory distress 2nd to
status asthmaticus precipitated by allergen exposure
OR
iii. 14 yo Hispanic male Known to have severe CP-MR,
bed ridden with seizure disorder and chronic lung
disease 2nd to recurrent aspiration syndrome.
Tracheotomy and GT in Place admitted in moderate
respiratory distress 2nd to recurrent aspiration
pneumonia
H&P and Past Medical hx, (Optional)
a. If patient is a LH patient f/u in the OPD, NO NEED TO
WRITE OR CUT AND PAST H&P, just write “See HPI in
admission note”
b. For patients who are being follow up outside: CUT AND
PAST HPI from admission note and/or summarized.
PICU course: uncomplicated OR complicated with: write System by
system, starting with Patients presenting condition in the ED admitting
and carry on course by system, mentioning Only relevant abnormal
values / studies. Mention if any consults and recommendations given.
1. Neurology (Neurosurgery if trauma).
2. Respiratory.
3. Cardiovascular
4. FEN (mention admitting and discharge weight if prolonged
hospitalization, specially for infants.)
5. Hematology
6. GI
7. GU (Renal)
GUIDE LINES FOR RESIDENT’S ON LINE PATIENT DOCUMANTATION IN THE PICU
PICU DISCHARGE SUMMARY GUIDELINES
Pediatric D/C Summary Note
August 16, 2007
8. Infection
9. Psychosocial (mentions parents’ involvement and if there were any
social issues address by social services.
10. Others (Such as specific trauma / accidents / drug overdose related)
Example: (patient with status asthmaticus)
Neurology: remained alert and oriented.
Respiratory: Patient presented to ER in severe respiratory distress with
significant desaturations (80 % in RA), treated aggressively with
bronchodilators and MgS. With mild improving, transferred to PICU for
further management. CxR did showed significant hyperinflation and PBT
only. CBC …etc.
on admission started on frequent nebulizer treatments albuterol and
Albuterol alternated every 30 min, IV Steroids and Oxygen. Initially he
required 50 % given by aerosolized mask to keep saturations > 95 %.
ABG showed ……., He improved gradually on Hosp Day # he was
oxygenating well on RA, PEFR improved from 120 to 350. He did have
productive cough and nasal discharge.
At present he’s breathing comfortable RR 15, Lungs auscultation shows
etc etc.
Med. Started on control therapy with Flovent …..
Cardiovascular: resolved tachycardia no other issues
FEN: Initially NPO for respiratory distress, on IV Fluids. Mild transient
hypokalemia with K of 3.1 most likely 2nd to frequent albuterol
treatments, improved on IV fluids with KCL. Last K 4.3. No other issues.
Hematology: mildly elevated WBC, no shift but eosinophylia.
GI: no issues, initially NPO now tolerating full PO well.
GU /Renal: no issues, normal urine output. No studies done except for
lytes. Normal BUN and Cr.
Infection: remained afebrile but had productive and sings of infected
rhinitis, treated with Zytromax.
Psychosocial: Single mother on public assistance. Had problems with
insurance and was unable to fill out prescriptions for control therapy.
MGM smokes at home. Patient referred to social services. VN requested.
OTHERS. If needed.
Assessment :
1. 17 yo African American male Known to have severe persistent
asthma, poorly controlled admitted in severe respiratory distress
2nd to status asthmaticus precipitated by allergen exposure. S/P
intubation. Respiratory distress resolved
2. Left lung collapse, resolved
3. Allergic / Infected rhinitis, early sinusitis (clinically) improving on
antibiotics
GUIDE LINES FOR RESIDENT’S ON LINE PATIENT DOCUMANTATION IN THE PICU
PICU DISCHARGE SUMMARY GUIDELINES
Pediatric D/C Summary Note
August 16, 2007
Plan:
1. D/C home with mother
2. Asthma education reinforced, AAP given and explained
3. Continue control therapy with: Flovent (220) 2 puff BID with
spacer, Singulair 10 mg QHS
4. Albuterol PRN
5. Complete 5 days of Prednisone 60 mg QD
6. Complete 10 days of Antibiotics. Augmentin….
7. Asthma education reinforced, AAP given and explained
8. Continue control therapy with: Flovent (220) 2 puff BID with
spacer, Singulair 10 mg QHS
9. Complete 5 days of Prednisone 60 mg QD
10. Complete 10 days of Antibiotics. Augmentin….
11. VNS service requested
12.F/U in the Asthma /Chest clinic in 5 days and PMD in x days
Seen and discussed with attending Dr. (WRITE NAME)
Discharge Condition and Plan (entered in Discharge orders)
 Status: Patient condition options: chose options or free text as applies to patient
 Dispo: Chose options or free text as applies to patient. Example: home with mother or Foster
mother)
 Activity: Chose options or free text as applies to patient. Example: for infants “back to sleep” ect.
 Diet: Chose options or free text as applies to patient
 Meds:
i. Name (Generic)
ii. Preparation concentration
 Liquid: -----mg/mL (-----mg/5 mL)
 Tablets: ------mg /tablet
 Nebulizer Solution: ------ mg/ml
 MDI: mg / puff, i.e.: Flovent 110
iii. Dose per kg / day OR
per kg / dose
iv. Duration of Therapy
 Appointments
 Any specific Instructions to follow up, pending results and / Or repeat studies etc.