Pediatric Gastroenterology Inpatient Progress Note

Date/Time: [date and time]

Author: [name, credentials, role]

Patient: [name, MRN, DOB, location, hospital day]

Primary Team: [service/team name]

Admission Date: [date]

Patient Snapshot

[1–2 sentence orientation including age, key GI diagnosis or reason for GI involvement, and current relevant supports such as nutrition route, lines, and key comorbidities affecting GI care] (Update only when materially changed.)

Interval Events

[Brief bullets capturing changes since last GI note: new symptoms, output changes, procedure results, medication adjustments, or family concerns affecting the plan] (If no significant changes, document: "No significant interval events.")

Subjective

Historian/Source: [parent / patient / RN / chart] (If subjective unobtainable, state reason and alternate source of interval history.)

[GI-relevant symptoms including abdominal pain with location/severity/response to treatment, nausea/vomiting, stool pattern with frequency/character/blood or mucus, appetite, and feeding tolerance] (Include brief caregiver quote only for high-impact concerns.)

Objective

Vitals: [pertinent values and trends]

I/O (24h): [summary emphasizing GI outputs—emesis, stool count/character, ostomy output in mL/kg/day if measured, tube drainage] (Note if measurements unreliable.)

Weight: [today vs yesterday, trend]

Exam: [general appearance, hydration, abdominal findings including distension/tenderness with location/bowel sounds/organomegaly, other pertinent findings] (State "not assessed" with reason if exam deferred.)

Data: [pertinent labs with brief trend interpretation, relevant imaging/procedure results, pending studies] (Import only reviewed, GI-relevant data.)

Nutrition: [current diet/feeding regimen including route, formula, rate, tolerance; TPN if applicable; dietitian involvement]

GI Medications: [GI-relevant medications with recent changes noted]

Assessment & Plan

(Number problems by acuity with GI issues prioritized.)

1. [Problem]: [current status and response to therapy] — [plan including diagnostics, therapeutics, and monitoring parameters with explicit triggers, e.g., "if stool output exceeds X mL/kg/day, reassess feeds"]
2. [Problem]: [assessment] — [plan]
3. [Additional problems as needed]

[Discharge milestones if applicable, e.g., tolerating goal feeds, bleeding resolved, outpatient follow-up arranged]

Summary for Primary Team: [brief consolidated recommendations with key contingencies and when to re-page] (Include for consult notes.)

Attestation: [per institutional policy]

(Omit sections not performed. When omission might imply completion, explicitly state "not assessed" or "not discussed today." Do not infer normal findings without documentation.)