PEDIATRIC H&P / CONSULT NOTE
Chief Complaint: ***
History of Present Illness:
.NAME is a .AGEPEDS .SEX who presents with ***.
Associated symptoms: {HX ACUTE ILLNESS SX PEDS NCAL:25967}.
Exposures: { :23569::None known}.
was given { :26092}.
After treatment, his condition is { :23578}.
Review of Systems:
Positive for { :23573::no other symptoms}
Negative for { :23573::no other symptoms}
Past History:
.PMH
.PSH
PCP: .PCP
.ALLERGY
Outpatient Medications:
.MED
Development: {DEVELOPMENTAL MILESTONES:23855::Within normal limits}
Immunization status: { :15306::Up to date and documented}.
Social Hx:
Lives with {GEN FAMILY MEMBERS:23926::both parents.}
Passive smoke exposure: {YES/NO:22695::No}
Travel History: {YES/NO:22695::no}
Pet Exposure: {YES/NO:22695::no}
Day Care: {YES/NO:22695::no}
School grade and performance: ***
{PED ADOL RISK BEHAVIOR (PEDS-NCAL):261715} This is a good addition for
teens needing heads assessments
Family History:
.FAMHX
Physical Exam:
.vs
General: { :23582::well appearing,no acute distress}
Head: {PE HEAD PEDS NCAL:25087}
Eyes: { :24003::normal eye exam}
Ears: {PE EAR NCAL PEDS:25088}
Nose: {PE NOSE NCAL PEDS:25090}
Mouth: { :23619::normal mouth and throat}
Neck: {PE NECK PEDS NCAL:25091}
Chest/Breast: {PE CHEST/BREAST PEDS NCAL:25092}
Lungs: { :23625::respiratory effort normal - no retractions, normal air exchange,
lungs clear bilaterally}
Cardiovascular: {PE HEART:26479}
Abdomen: {PE ABDOMEN:25093}
Lymphatic: {PE LYMPHATIC PEDS NCAL:25105}
GU: {PED PE GU GENERAL:261039}
Back: {PE BACK PEDS NCAL:25098}
Extremities: {PE EXTREMITIES:25101}
Neuro: {PE NEURO:25099::alert and oriented,age appropriate symmetric
reflexes,moves all extremities symmetrically}
Skin: {PE SKIN PEDS NCAL:32008}
Labs:
***
Studies:
***
Assesment / Plan:
{GEN ASSESSMENT PLAN :261344}
.sign
PEDIATRICS DISCHARGE SUMMARY / NOTE
Date of Admission: .ADMITDT
Date of Discharge: .TDNR***
Attending Physician: .ATTPROV
Resident Physician: ***
Admitting Diagnosis: ***
Principal Diagnosis(Discharge Diagnosis): .prinprob
Secondary Diagnoses:
.resolvedproblems
Consults: {GEN NONE 2B:22192}
Procedures: {GEN NONE 2B:22192}
Pending Labs and Tests at discharge: ***
Pending Results: {GEN NONE 2B:22192}
Brief H&P:***
Discharge Exam
{PE SUPEREXAMS PEDS NCAL:25104}
Hospital Course:***
.resolvedproblems
Code Status: ***
Condition on Discharge: {GEN CONDITION AT TIME OF DISCHARGE (PEDS) IP
NATL:25160}
Discharge Disposition: Home ***
Activity: ***
Diet: ***
Follow up appointments: ***
Discharge Medications: .takehomemeds
.sign
PEDIATRICS PROGRESS NOTE
{GEN IP PROGRESS NOTE HEADER:261343}
Vital Signs:
.vs .vs1d can also be subsitituted here, I think this may work better for our unit
Intake and Output:
.vs1d
{PEDIATRIC PHYSICAL EXAM:270592}
Labs:
.labslist
*** Culture ***
Studies: ***
Assessment and Plan:
{GEN ASSESSMENT PLAN:261344}
.sign
PICU PROGRESS NOTE/PICU ATTENDING
{GEN IP PROGRESS NOTE HEADER:261343}
Objective: {VITAL SIGNS AND WEIGHTS:268060}
{PEDIATRIC PHYSICAL EXAM: 270592}
{:268068}
Neuro: ***
Resp: ***
.ventdata4
CV: Warm and well perfused without support.
Renal: ***
Urine Ouput ***mL = ***mL/kg/hr
.IOBRIEFNR
Heme: ***
.LASTHCT
.LASTPLT
ID: ***
.LASTWBC
Endo: ***
.LASTGLC
GI: ***
Psycho/Social: Current status and plans discussed with *** at bedside. Message
left for .PCP and ***
.SIGN