Pediatric Nephrology Inpatient Progress Note

Date/Time: [Date and time of note]

Note Type: Pediatric Nephrology Inpatient Progress Note

Author/Role: [Author name and credentials]

Location: [Unit/bed]

Hospital Day: [#] / Nephrology Day: [#]

Primary Team: [Service]

Consult Reason: [Reason]

(Prioritize brevity and actionability for cross-coverage. Omit sections that do not apply. Do not fabricate data. Use explicit placeholders only when data absence matters clinically.)

Clinical Snapshot

[1–2 sentence summary: patient age, pertinent clinical context, primary kidney issue with AKI stage if applicable per KDIGO, current RRT status (none/HD/PD/CRRT), and key acuity marker (e.g., oliguric, fluid overloaded, improving creatinine)]

Assessment & Plan

[Global nephrology assessment in 2–4 sentences: current kidney diagnosis and trajectory (improving/stable/worsening), likely drivers, RRT status and goals, and biggest risk(s) for the next 24 hours]

[Problem 1: Concise label]

Status: [1–2 sentences with key objective anchors: creatinine/BUN trend vs baseline, UOP in mL/kg/hr, weight change, pertinent labs]

• Plan: [Diagnostics, therapeutics, and monitoring targets with timing and rationale]
• Safety: [Nephrotoxin avoidance/mitigation; renal dosing adjustments; access protection]
• Contingencies: [If/then triggers with exact thresholds, actions, and who to notify] (Required for high-risk problems.)

[Problem 2: Concise label]

Status: [Key objective anchors]

• Plan: [As above]
• Safety: [As above]
• Contingencies: [If/then triggers]

(Include only active problems. Add or remove problem blocks as needed. Common problems: AKI/AKD with staging and etiology, fluid overload, electrolyte disorders, acid-base disturbance, hypertension, nephrotoxin stewardship.)

Renal Replacement Therapy

(Include only if patient is on RRT.)

Modality: [HD / PD / CRRT] for [indication]

• Prescription: [CRRT: effluent rate in mL/kg/hr, net UF goal, anticoagulation. HD: next session timing, UF goal. PD: dwell volume in mL/kg, cycles, net UF target.]
• Access: [Site/type, day since placement, function, any concerns]
• Performance: [UF achieved vs goal; interruptions/downtime; circuit issues] (Do not infer delivered dose if metrics unavailable.)
• RRT Plan: [Parameter changes, UF goal, session timing for next 24h]
• Contingencies: [If/then triggers for hypotension, clotting, access issues, circuit failure]

Interval Update & Subjective

• [Overnight events impacting kidneys/fluids: hypotension, pressor changes, nephrotoxin exposure, procedures] (If uncertain, state "no interval events documented.")
• [RRT issues if applicable: circuit problems, UF intolerance, access dysfunction]
• [Patient/family-reported concerns: urine output, swelling, thirst, dialysis tolerance]

(If sedated or nonverbal, state that no subjective can be obtained.)

Objective

Vitals/Weight: [Current vitals; today's weight with change from yesterday and admission; note measurement limitations if present]

I/O & Fluid Balance: [24h intake, output, net; UOP in mL/kg/hr with measurement method; fluid restriction and IV composition] (Note if I/O data is missing: "I/O not charted since [time]—unable to assess UOP trend.")

Nephrology-Relevant Meds: [Diuretics with response; active nephrotoxins with mitigation; electrolyte therapies; antihypertensives; renal dosing adjustments]

Focused Exam: [Volume status: edema, lung findings, perfusion, mucous membranes; access site findings if applicable; uremic signs if present; note exam limitations]

Labs: [BUN/creatinine with baseline or state unknown, electrolytes, acid-base—presented as trends with interpretation; state how AKI is staged if baseline unknown]

Imaging/Devices: [Kidney-relevant imaging if obtained; dialysis access status if applicable] (Omit if none relevant.)

Communication

• [Recommendations discussed with primary team/ICU/nursing/pharmacy; key points and agreed plan; method if not in-person]
• [Family/guardian communication: topics discussed, shared decisions, consent if applicable]