Pediatric Inpatient Admission History & Physical

Date/Time: [Encounter start date and time]  |  Location: [Hospital name and unit]  |  Service: [Peds Hospital Medicine / PICU / NICU / Pediatric Subspecialty]  |  Admission Source: [ED / Direct admit / Transfer]  |  Admission Status: [Inpatient / Observation / Unknown]

Patient: [Name], [MRN], [DOB], [Age] (Use days for neonates, months for infants, years for older children.)
Guardian/Consent: [Legal guardian, custody status if relevant, caregiver at bedside with relationship] (If guardian status is unclear, state uncertainty and plan to clarify.)

Historian & Data Sources

[Primary historians and reliability assessment] (Brief rationale if limited.)
[Interpreter use: language and modality, or state not required]
[External records reviewed] (Keep to 2–4 concise lines.)

Chief Complaint

[Presenting concern in caregiver/patient words with duration]

History of Present Illness

[One-liner summary: age, pertinent history, presenting syndrome, acuity]

[Chronology of symptom onset, course, severity, associated symptoms, and key pertinent negatives] (Focus on findings that narrow the differential.)

[Hydration status, oral intake, urine output, stooling, activity level] (Specify if information is unknown and plan to quantify.)

[Home therapies tried and response; sick contacts and daycare exposures; recent travel]

[ED/OSH course: key interventions including fluids, oxygen, medications, labs, imaging, and response]

[Infant-specific features when relevant: feeding pattern changes, breathing during feeds, color changes, apnea episodes]

[Rationale for admission: e.g., persistent hypoxemia, failed PO trial, need for IV therapy, monitoring needs]

Birth & Perinatal History

[Gestational age, prenatal complications or exposures, delivery mode, birth weight, NICU course if applicable] (Include for infants/toddlers or when clinically relevant; omit for older children with unrelated problems.)

Past Medical History

• [Chronic diagnoses and baseline functional status]
• [Prior similar episodes and prior hospitalizations]
• [Involved specialists and baseline care plans]

(If none, state: No known chronic medical conditions.)

Past Surgical History

• [Surgeries and dates]
• [Implanted devices, lines, shunts, G-tube, tracheostomy, prior intubations]

(Omit section if none.)

Medications

• [Home medications: name, dose, route, frequency, indication]
• [Recent antibiotics and/or steroids]
• [Relevant OTC and PRN medications]
• [Adherence issues if relevant]

(If not fully confirmed, state: Home meds not fully confirmed—pharmacy/PCP to verify.)

Allergies

• [Medication allergies with reaction type and severity]
• [Relevant food allergies and latex allergy]

(If uncertain, document uncertainty. If none: No known drug allergies.)

Immunizations

[Immunization status and source] (Caregiver report vs registry-confirmed vs records unavailable. Note influenza/COVID-19 status when relevant. If under-immunized or unknown, document plan to obtain records.)

Growth & Development

• [Baseline diet and feeding method]
• [Developmental milestones or concerns]
• [Baseline functional status for medically complex children]

(Include for infants/young children or when relevant to hydration, FTT, chronic disease, or developmental concerns; omit otherwise.)

Family History

[First-degree relatives with conditions relevant to admission: atopy/asthma, congenital heart disease, seizures, bleeding disorders, hemoglobinopathies, autoimmune disease, sudden cardiac death, metabolic disorders] (Keep focused on clinically relevant conditions.)

Social History

• [Household composition and primary caregivers]
• [School/daycare attendance]
• [Smoke/vape exposure, pets, housing concerns]
• [Recent travel or notable exposures]
• [Adolescents: document if private time obtained; HEADSS assessment per policy with sensitive details in confidential note as appropriate]

(If unable to obtain, document reason and plan to reattempt.)

Review of Systems

[Targeted ROS pertinent to admitting syndrome; address hydration, fever, respiratory effort when relevant] (A brief statement such as "ROS otherwise negative except as in HPI" is acceptable. May omit for critically ill patients when history was limited by acuity.)

Vital Signs & Anthropometrics

• Vitals: [Temp, HR, RR, BP, SpO2 with oxygen requirement and delivery device]
• Weight: [Weight in kg] (Specify measured vs estimated.)
• Length/Height: [Length or height; head circumference for infants]

Dosing Weight: [Weight used for medication dosing] (State whether equals today's measured weight; note exceptions such as obesity/ideal body weight per institutional guidance.)

Physical Examination

• General: [Appearance, distress level, hydration status, interaction]
• HEENT: [Head, eyes, ears, nose, throat findings]
• Neck: [Suppleness, lymphadenopathy, rigidity]
• Cardiovascular: [Rate/rhythm, murmurs, perfusion, pulses, capillary refill]
• Respiratory: [Work of breathing, breath sounds, retractions, wheeze/crackles/stridor]
• Abdomen: [Soft/firm, tenderness, organomegaly, bowel sounds]
• Genitourinary: [Findings when indicated]
• Skin: [Rashes, color, turgor, lesions]
• Musculoskeletal: [Range of motion, tenderness, swelling, deformities]
• Neurologic: [Mental status, tone, strength, focal deficits]
• Psychiatric: [Mood/affect, behavior, thought content] (Include for adolescents when relevant.)
• Lines/Tubes/Devices: [Type, site, function, date placed]

(If any portion of the exam is limited, state the limitation and reason.)

Diagnostics

Labs

• [Key abnormal results with interpretation and trends]
• [Critical values acknowledged and actions taken]

Microbiology

• [Cultures obtained with collection times; rapid tests; PCR panels]
• [Pending studies and follow-up plan]

Imaging

• [Study type, date/time, key findings with clinician interpretation]
• [Pending imaging and follow-up plan]

Assessment

[Concise summary: age, key history, presenting problem, objective severity markers, current status. Working diagnosis and prioritized differential when uncertainty exists. Address high-risk considerations explicitly. Include rationale for level of care and anticipated trajectory.] (Keep to 1–2 short paragraphs; do not repeat HPI.)

Plan

[Problem 1: Diagnosis or clinical syndrome]

[Brief assessment: 1–2 lines with key supporting data]

• Diagnostics: [Planned tests with timing and indications]
• Therapeutics: [Medications with mg/kg dose, calculated dose, route, frequency, max dose cap; respiratory support with weaning plan; fluids/nutrition with calculations; antibiotic rationale; isolation precautions]
• Monitoring: [Vital sign frequency, oximetry/telemetry, neuro checks, I/O goals]
• Consults: [Services and specific questions]
• Escalation Triggers: [Objective criteria for escalating care]
• Lines/Devices: [Indications and removal criteria]
• Pain/Fever Control: [Analgesic/antipyretic plan with dosing]
• Discharge Criteria: [Objective targets for safe discharge]

[Problem 2: Diagnosis or clinical syndrome]

(Repeat structure for additional active problems; order by acuity with most urgent first.)

Disposition & Communication

• Level of Care: [General pediatrics / Step-down / PICU] (Include rationale.)
• Expected Discharge Criteria: [Clinical milestones and stability requirements]
• Expected Timeline: [Anticipated duration of hospitalization]
• Follow-Up Needs: [PCP and specialist follow-up; pending tests requiring results review]
• Family Communication: [Caregivers present, understanding, shared decisions]
• Care Coordination: [Case management/social work involvement; equipment, home services]