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{This section will be copied and pasted into the Clinical Assessments Section}
Neuro:
patient remained with normal activity for age, not in distress, {pain well
controlled },interacting with medical staff and mother
Resp:
RR:
Cardiac:
HR BP
O2Sat:
/
FEN
Total Input: ; Urine Output: ; SMA done showed Na K Cl CO2 Glu
BUN Creat Ca,
Nutrition
On regular diet, no issues. Admission Wt: Today's Wt: gain/loss of
Hema
CBC done showed H/H of _____ Retic Ct. _____. No issues
GI
no vomiting or diarrhea. Last BM was
Renal/GU
good urine output, last UA was wnl
Infxn
Patient has been afebrile for > ___ hrs. Last CBC showed WBC of ____
with ____ shift . Vaccinations status.
Psych
Mother at bedside involved in patient care. No insurance issues. seen and
evaluated by SW with no issues
Others
{Assessment / Plan Section}
HD# / PICU Day#
Assessment:
{age,ethnicity/race,sex, # of hospitalizations,previous diagnoses/status, chronic
conditions, reason for admission, acute/resolved or resolving conditions, current
condition including new acute or active problems - number problems if necessary,
overall condition}
{Overall Condition Examples:

Remains critical unstable OR

Improving by still critical

Serious, (respiratory failure, severe anemia,) slow improving OR worsening Or
intermittent)

Guarded (patient is better /stable but still condition may deteriorate)

Improving Stable, (this will qualify a patient ready for discharge or transferred to
floor.?
Plan:
Continue VS q { } hrs
Continue I&O q { } hrs
{Medications and changes}
{Studies to be done}
{Consults to be done or requested}
Condition and current treatment discussed with parents
Case seen and discussed with Attending Dr.