Pediatric Consultation Note (Inpatient/ED)

Date/Time: [date and time of evaluation]

Patient: [name], [age with appropriate units: days/weeks/months/years], [male / female / intersex / unknown]

Weight: [measured weight in kg with source and date if not measured today] (If unavailable: ⚠ Weight required—obtain measured weight before any weight-based dosing)

Gestational/Corrected Age: [gestational age in weeks+days; corrected age] (Include for neonates and young infants; omit if not applicable.)

Location: [ED / inpatient unit with bed]

Consulting Service/Clinician: [service and clinician name/role]

Requested By: [requesting service/clinician]

Urgency: [routine / urgent / emergent]

Historian: [parent / guardian / patient / EMS / chart] (Note interpreter language if applicable.)

Reason for Consultation

[Single sentence stating who requested the consult, the specific problem, and what decision or action is being requested, including any time-sensitive expectation] (Be explicit; avoid vague phrases like "evaluate and treat.")

Clinical Summary

[One to two sentences synthesizing age, key history, presenting problem, current severity and trajectory, and why the consult is needed now]

History of Present Illness

[Focused narrative tied to the consult question: onset and timeline, trajectory, severity, pertinent positives and negatives that discriminate the differential, prior therapies and responses, current supports, and contextual factors such as exposures, sick contacts, or ingestion risk] (Do not reproduce the full ED or admission H&P.)

Pertinent Background: (Include only elements relevant to the consult question.)

• [Relevant chronic conditions and technology dependence]
• [Birth history for infants; developmental baseline for neuro or behavioral concerns]
• [Current medications with last doses of critical meds]
• [Allergies with reaction types; state "unknown" if not verified]
• [Immunization status if relevant to infectious differential]
• [Relevant social or exposure history]

Physical Examination

Vitals: [HR, RR, BP, Temp, SpO2, weight in kg] at [timestamp] (If a key vital is not obtained, state "not obtained" with reason.)

• General: [appearance, interaction/consolability, distress level]
• Hydration/Perfusion: [mucous membranes, capillary refill, skin turgor, extremity temperature]
• Respiratory: [work of breathing, breath sounds, retractions, adventitious sounds]
• Cardiovascular: [heart sounds, pulses, perfusion]
• Neurologic: [age-appropriate alertness, tone, focal deficits]
• Abdomen: [tenderness, distension, organomegaly]
• Skin: [rashes, color, lesions]
• Other systems pertinent to consult: [focused findings]

(Document only systems examined. If a key component could not be performed, state why.)

Data Reviewed

• [Key laboratory results with dates/times and brief interpretation]
• [Microbiology with dates/times and interpretation]
• [Imaging with dates/times and interpretation; note if personally reviewed]
• [Other studies: ECG, EEG, etc. with interpretation]
• [Outside records reviewed with relevant summary]
• [Interprofessional discussions that informed decision-making]

Assessment

Answer to consult question: [One to two sentences directly answering the consult question]

(List problems in order of severity. For each, state the working diagnosis, key evidence, differential considerations, and severity or risk features. Note important uncertainty where present.)

[Problem 1]: [Working diagnosis or clinical syndrome]

• Key evidence: [salient findings supporting the impression]
• Differential/uncertainty: [conditions to consider] (Include only if it meaningfully affects management.)
• Risk/severity: [severity features, decompensation risks]

[Problem 2]: [Working diagnosis or clinical syndrome]

• Key evidence: [salient findings]
• Differential/uncertainty: [as applicable]
• Risk/severity: [as applicable]

Recommendations

(Provide specific, actionable, problem-based recommendations with explicit units. Require measured weight before any weight-based dosing if unconfirmed.)

[Problem 1]: Recommendations

• Diagnostics: [tests with timing and indication; who orders]
• Therapeutics: [medication] [dose mg/kg] (max [dose]) [route], [frequency], [duration]; [non-pharmacologic interventions]
• Monitoring: [parameters, thresholds, frequency]
• Disposition: [discharge criteria / admit level of care / ICU criteria]
• Contingency: [escalation triggers and actions, e.g., "If SpO2 remains below X% despite Y, notify Z team, consider ICU"]
• Ownership: [who is responsible for each action]

[Problem 2]: Recommendations

• Diagnostics: [as applicable]
• Therapeutics: [as applicable with mg/kg dosing and max dose]
• Monitoring: [as applicable]
• Disposition: [as applicable]
• Contingency: [as applicable]
• Ownership: [as applicable]

Consultant follow-up: [Will follow daily / Sign off, re-consult as needed / Arrange outpatient follow-up with service in timeframe]

(If consult influences ED disposition, include safe discharge criteria, follow-up timing and scheduling mechanism, and return precautions.)

Communication

• [Who contacted] — [timestamp] — [phone / in-person / EHR message] — [key points communicated] — [acknowledgment received: yes / no]

Signature

[Electronic signature: name, credentials, role, service] | [contact information for urgent changes]