Pediatric Neurology Discharge Summary

Patient name: [Patient full name]; DOB: [DOB]; MRN: [MRN]; Age at discharge: [Age]

Admission date/time: [Admission date and time]; Discharge date/time: [Discharge date and time]; Length of stay: [Length of stay]

Admitting service: [Admitting service]; Discharging service: [Discharging service]; Attending neurologist: [Attending pediatric neurologist]

Primary caregiver/guardian: [Name and relationship]; Preferred language: [Preferred language] (Note interpreter use if applicable)

PCP: [PCP name]; PCP contact: [Phone/fax]; Outpatient neurology contact: [Clinic name and phone]

Disposition: [home / inpatient rehabilitation / acute care transfer / skilled nursing facility / long-term acute care / hospice / other]

Summary

[Brief hospitalization overview including reason for admission, key diagnostic conclusions, major interventions, neurologic status at discharge compared to baseline, and most critical follow-up actions] (3–6 sentences)

Discharge Diagnoses

• [Principal neurologic diagnosis] (For seizures/epilepsy: include seizure classification [focal / generalized / unknown], etiology [structural / genetic / metabolic / infectious / immune / unknown], and epilepsy syndrome if established)
• [Secondary neurologic diagnoses]
• [Relevant non-neurologic comorbidities]
• [In-hospital complications] (If any)
• [Working diagnosis and key differentials] (If diagnosis remains uncertain)

Allergies and Adverse Reactions

• [Drug allergen]: [Reaction type] — [Severity]
• [Significant adverse drug reactions]: [Agent] — [Reaction]
• [Relevant food/latex allergies impacting plan]

(State explicitly if allergy history is unknown)

Hospital Course

(Organize by problem in order of clinical priority. Use problem headings relevant to the admission.)

[Problem 1]

• Diagnostic conclusion and key data: [Summary with key findings and dates]
• Therapies and response: [Therapies provided, doses, dates, and clinical response]
• Status at discharge: [Current status compared to baseline]
• Discharge plan: [Home plan, monitoring, precautions, follow-up actions]

[Problem 2]

• Diagnostic conclusion and key data: [Summary]
• Therapies and response: [Summary]
• Status at discharge: [Summary]
• Discharge plan: [Summary]

[Seizures/Epilepsy]

(Include when seizures or status epilepticus were part of the presentation)

• Pre-admission seizure history: [Baseline frequency, semiology, known triggers, prior rescue plan]
• Inpatient seizure burden: [Number and type of events, clustering or status if any]
• EEG: [Date] — [Type] — [Background, interictal activity with location, seizures captured yes/no, clinical correlation]
• ASM management: [Selection rationale, starting dose, titration schedule, target dose, serum level targets if applicable]
• Rescue plan and caregiver teaching: [Rescue medication with route, dose, and threshold; caregiver education completed yes/no; forms provided yes/no]
• Seizure emergency definition: [Time threshold or cluster criteria and escalation steps for this patient]
• Status at discharge: [Seizure control and neurologic status versus baseline]

Diagnostics

EEG

• [Date] — [routine / continuous / video] — [One-line impression: background, interictal epileptiform activity with location, seizures captured yes/no, clinical correlation]

(If EEG was expected but not obtained, document the reason)

Neuroimaging

• [CT / MRI brain / MRI spine] — [Date] — [One-line clinically relevant impression with comparison to prior if available]

Laboratory/CSF

• [Key abnormal or decisive normal results that influenced management] — [Date] — [Clinical relevance]

Genetic/Metabolic Testing

• [Test name] — [Date sent] — [pending / completed] — [Expected turnaround] — [Who will follow up and notify family]

Other Neurodiagnostics

• [EMG / NCS / evoked potentials / therapy evaluations] — [Date] — [One-line impression]

(Omit subsections with no applicable studies)

Procedures and Devices

• [Procedure name] — [Date] — [Indication] — [Outcome/complications]
• [Implanted device: VP shunt / VNS / baclofen pump] — [Settings or adjustments during admission] — [Precautions]

(Omit section if no significant procedures or devices)

Discharge Examination

(Focused pediatric neurologic exam with explicit comparison to baseline. Include exam date if not day of discharge.)

• Date of exam: [Date]
• Mental status/behavior: [Findings compared to baseline]
• Cranial nerves: [Findings]
• Strength/tone: [Findings]
• Coordination/gait: [Findings]
• Reflexes: [Findings]
• Sensation: [Findings]
• Functional status: [Feeding, mobility, communication, school/daycare readiness]
• Neurologically relevant vitals: [BP targets or other parameters] (Only include if relevant to plan)

Discharge Condition and Supports

Condition: [stable / improved / worse]; [at neurologic baseline / persistent deficits: specify]

Supports: [Home nursing, PT, OT, SLP, Early Intervention, DME] (Note any barriers: transportation, caregiver readiness, insurance/authorization issues)

Medications

Weight at discharge: [Weight in kg]

Scheduled Medications

• [Generic name] — [Dose] — [Route] — [Frequency] — [Indication] (For liquids: include concentration in mg/mL and dose in both mg and mL; for weight-based dosing: include mg/kg/day)

PRN Medications

• [Generic name] — [Dose] — [Route] — [Frequency/criteria] — [Indication]

Rescue Medications

• [Agent and formulation] — [Dose in mg and mL with concentration] — [Route] — [Threshold for use] — [Maximum doses and repeat rules]

Medication Changes

• New medications: [Medication and rationale]
• Discontinued medications: [Medication and reason]
• Dose changes: [What changed and why]
• Titration/taper schedule: [Explicit schedule with dates]
• Required monitoring: [Labs, drug levels, side effects to watch; timing]
• Access issues: [Prior authorization status, pharmacy availability, contingency plan]

Seizure Action Plan

(Include when seizures or epilepsy are part of the presentation. Use caregiver-friendly language.)

Seizure First Aid

[Core seizure response steps: stay calm, time the event, keep child safe, position on side, do not restrain or put anything in mouth, observe breathing and color]

Rescue Medication

• When to give: [Time threshold or cluster definition]
• What to give: [Medication, dose, route-specific administration technique]
• Repeat dosing: [Repeat rules and maximum daily dose]

When to Call 911

• [Seizure duration threshold despite rescue medication]
• [Breathing difficulty, cyanosis, or serious injury]
• [Repeated seizures without recovery between]
• [First-time seizure or caregiver uncertainty]

Safety Precautions

• Water safety: [Supervision requirements for bathing/swimming]
• Activity restrictions: [Heights, bikes/helmets, cooking, machinery]
• Sleep: [Monitoring or arrangements if relevant]

School/Daycare

[Seizure action plan form provided/updated: yes/no] — [Recipient: school nurse, daycare, other]

SUDEP Counseling

[SUDEP risk and risk-reduction strategies discussed with caregivers: yes/no] (Document when epilepsy is diagnosed or clinically indicated)

Missed Dose Instructions

[Instructions for late or missed doses specific to this patient's medication regimen]

(If events were determined to be non-epileptic, document tailored response plan that avoids inappropriate rescue medication use and outlines appropriate follow-up pathway)

Follow-Up Plan

• Neurology: [general / epilepsy / neuromuscular clinic] — [Timeframe] — [Purpose]
• PCP: [Timeframe] — [Purpose]
• Other subspecialties: [Neurosurgery / genetics / psychology / rehab / other] — [Timeframe] — [Purpose]
• Planned testing: [EEG / MRI / labs / drug levels / genetic results] — [Indication] — [Target date] — [Who orders] — [Who reviews and notifies family]

(Use explicit placeholders when appointment details are not yet available)

Pending Results

• [Test name] — [Date sent] — [Expected turnaround] — [Responsible clinician] — [How family will be notified]

(If none: "No pending results." Never omit this section.)

Handoff Communication

• Discharge summary sent to: [PCP, outpatient neurologist, other]
• Key messages for receiving team: [Actions needed if pending results abnormal, monitoring needs, specific return precautions]
• Contact for urgent questions: [Inpatient team contact during transition and/or outpatient clinic contact]