Pediatric Cardiology Inpatient Progress Note

Date/Time: [Date and time of note entry]

Author/Service: [Author name, credentials, and service/team affiliation]

Patient: [Patient name and identifiers per local policy; age/sex]

Location: [Unit and level of care: CICU / step-down / floor; isolation status if applicable]

Hospital Day: [HD#]

POD #: [POD# and procedure name] (Only include if post-operative.)

Device Day: [ECMO Day # / VAD Day #] (Only include if applicable.)

Primary Cardiac Diagnosis: [Primary cardiac anatomy/diagnosis]

Weight (kg): [Current weight (kg)] (Include dosing weight if different. Specify date measured.)

Summary

[One-liner: age, major diagnosis/anatomy, s/p procedure if applicable with POD#/HD#, current support level, and brief trajectory statement]

Interval Events (last 24h):

[Significant events that changed management or risk, including hemodynamic changes, rhythm events, support changes, procedures, infectious concerns, feeding changes, or major family communication] (If none, state "No acute events overnight.")

Subjective

[Patient symptoms and caregiver concerns relevant to today's plan] (For verbal patients, include cardiac-relevant symptoms. For all patients, note feeding tolerance, activity/comfort level, and parent questions affecting care.)

Source: [Who provided history] (Always specify, e.g., "Parent and bedside RN" or "Patient intubated/sedated; history per RN and chart review.")

Objective

Vitals: [Current HR, BP/MAP, RR, SpO2, Temp; 24h ranges as relevant; CVP only if actively referenced]

I/O (last 24h): [Total intake, output, net balance; UOP in mL/kg/hr if used locally; chest tube output if present]

Support/Drips: [Respiratory device and settings if applicable; active continuous infusions with dose/units and changes from prior day]

Lines/Devices: [Central lines, arterial lines, chest tubes, pacing wires, ECMO/VAD hardware with site and day if tracked] (Note plan for removal or justification to continue.)

Data: [Key labs with trends, telemetry rhythm summary, ECG if new/relevant, imaging/echo findings if decision-driving] (Summarize concisely; do not paste full reports.)

Exam: [Pertinent findings: general appearance, work of breathing, cardiovascular (rhythm, perfusion, pulses, cap refill, edema, hepatomegaly), and other relevant systems] (Document only what was examined; omit systems not assessed.)

Assessment & Plan

(Problem-based combined assessment and plan. Order problems by acuity. Clearly state if key data are missing. For pending results, include contingent actions.)

[Problem name]: [Status/trajectory]

[Concise assessment with key supporting data driving today's decisions]

• Plan: [Actionable steps with specifics: medications with weight-based dosing and units, targets, monitoring, escalation/weaning criteria, timing, and responsible team if shared management]

(Repeat problem heading format for each active problem. Typical problem categories ordered by acuity: primary cardiac/post-op state, rhythm/EP, hemodynamics/support, respiratory, renal/fluids/lytes, heme/anticoagulation, ID, nutrition, sedation/mobility if ICU, lines/devices, disposition/family. Include only relevant problems for this patient.)

(Document today's condition and plan; do not carry forward prior assessments without updating.)

Electronic Signature: [Name, credentials]

Contact: [Pager/phone or secure messaging]