Pediatric Inpatient Daily Progress Note

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

Author: [Author name, credentials, role]

Attending of Record: [Attending name]

Service/Team: [Service or team name]

Location: [Unit/Room]

Hospital Day #: [Hospital Day number; include Post-Op Day if applicable]

One-Liner

[One-sentence patient summary including age, sex, relevant PMH, admission diagnosis, key hospital course anchor, and clinical trajectory] (Use months for age if under 2 years.)

Subjective

Overnight/Interval Events: [Significant events since last assessment including acute changes, therapies started/stopped/escalated, procedures, and nursing concerns] (If none, state "No acute events overnight.")

Patient/Caregiver Report: [Historian identification and symptom course including feeding/PO tolerance, output patterns, sleep, activity, and pain] (If history is limited due to caregiver absence, document this explicitly.)

Family Questions/Priorities: [Family concerns and questions for today, particularly those affecting decisions or discharge timing]

Objective

Vitals: [Current vitals and 24-hour trends as relevant] (Include respiratory support details if applicable.)

Weight/I&O: [Today's weight in kg with change from admission and yesterday; dosing weight if different] (Include I/O totals and UOP in mL/kg/hr when fluid status or renal issues are active.)

Exam: [General appearance and hydration status, then targeted system findings relevant to active problems] (Include pediatric-specific findings as appropriate: fontanelle, cap refill, tone, consolability. If exam is limited, explain why.)

Data: [Key new labs, culture status, and imaging with brief interpretation] (Include only results relevant to today's decision-making.)

Assessment & Plan

[Overall assessment: 1–2 sentences on current stability, trajectory, and primary drivers of continued inpatient need]

1. [Problem name]:

Assessment: [Status, trajectory, and objective anchors; emphasize what changed since yesterday]

Plan: [Therapeutics with weight-based dosing for new/changed medications, diagnostics, monitoring, consults, and contingency plans as applicable]

2. [Problem name]: (Continue numbering problems by priority.)

Assessment: [Status and trajectory]

Plan: [Relevant interventions]

(Keep each problem self-contained. Link plan elements to ongoing inpatient-level care requirements.)

Discharge Planning

Anticipated Discharge: [Target date/timeframe / TBD]

Criteria: [Patient-specific clinical milestones required for discharge, linked to active problems]

Barriers: [Clinical barriers, caregiver readiness/teaching needs, logistics, follow-up scheduling, and relevant social factors]

Coordination: [Case management involvement, subspecialty and PCP follow-up needs, pending studies that must result before discharge]

(If discharge is not being actively considered, state "Not nearing discharge; focus remains on stabilization.")