Pediatric Neurology Inpatient Progress Note

Header

Date/Time: [Date] [Time] | Hospital/Consult Day: [HD# / Consult Day#] | Author/Service: [Author name, role] – [Neurology/Child Neurology Service] | Attending of Record: [Attending name]

Patient Snapshot: [Age with relevant baseline developmental/neurologic status]; admitted for [reason for admission] with [primary neurologic syndrome]. Current supports: [cEEG / EVD-ICP / ventilator / ketogenic diet / none].

Interval Events (past 24h)

• [Timestamp] [Neurologic event or notable change—clinical/electrographic seizures, new deficits, encephalopathy changes, notable neuro checks, new EEG/imaging results, therapy responses/adverse effects, significant safety or family communication events]
• (Add additional events as needed with timestamps.)

(If no significant events, state explicitly. Do not infer absence of seizures unless documented by nursing, caregiver, or EEG.)

Subjective

[Patient/caregiver-reported symptoms: headache, nausea, weakness, sleep, feeding tolerance, behavior changes, caregiver questions/concerns] (If history is limited by sedation, intubation, developmental level, or encephalopathy, state this explicitly.)

Objective

• Vitals: [Temp, HR, BP, RR, SpO2] | Weight: [kg] (Include relevant trends if they impact today's decisions.)
• ICU Context (if applicable): [Sedation scale and agent(s)] | [Ventilator mode/settings]
• Neuro-Relevant Meds: [Current ASMs with doses; mark changes in last 24h; rescue medications used with response; sedation infusions affecting exam/EEG] (Do not include full medication reconciliation.)
• Pertinent Labs: [Abnormal or neuro-relevant results only—electrolytes, ASM levels, LFTs/ammonia if on valproate, CSF if applicable] (State date reviewed; do not paste full panels.)
• EEG Summary (when active or newly resulted):
  • Study: [Type (routine/continuous), timeframe, preliminary/final]
  • Context: [Indication, sedation status]
  • Findings: [Background, seizure burden with localization, interictal patterns]
  • Impression: [Normal vs abnormal with prioritized abnormalities]
  • Action: [Changes made, communication to team/family]
• Neuroimaging (new/updated only): [Modality, date] – [Key impression-level findings relevant to today's decisions]
• Neurologic Exam:
  • General/Arousal: [Appearance, alertness] (Note sedation or medical confounders.)
  • Mental Status: [Interaction, attention, orientation as age-appropriate] (State if not assessed and why.)
  • Cranial Nerves: [Pupils, gaze/EOM, facial symmetry, other CNs as examined]
  • Motor: [Tone, strength by limb, abnormal movements; document asymmetries]
  • Reflexes: [DTRs, plantar responses; brainstem reflexes for ICU patients] (If not assessed, state why.)
  • Sensory/Coordination/Gait: [Findings if assessed] (State if deferred and why.)

Assessment & Plan

Overall Impression: [improved / stable / worsened]; [leading neurologic diagnosis/syndrome]. [Today's key decision points or risks.]

[Problem 1 – specific diagnosis/syndrome]

Status: [Concise status with supporting facts from today and last 24h]

• Diagnostics: [Pending/ordered tests with timing; criteria to discontinue or escalate]
• Therapeutics: [Medication changes with weight-based rationale; procedures]
• Monitoring: [Neuro check frequency; seizure precautions; EEG continuation criteria]
• Contingencies: [If/then pathways for seizures or decline; rescue plan with dosing]

[Problem 2 – additional active issue]

Status: [Brief status]

• [Diagnostics, therapeutics, monitoring, contingencies as relevant]

(Add problems as needed, ordered by priority with life-threatening issues first.)

Disposition & Discharge Planning

(Include when discharge anticipated within 72 hours or complexity requires coordination.)

• Readiness/Barriers: [Clinical milestones required; outstanding diagnostics, therapy needs, equipment, home supports]
• Education: [Seizure first aid, rescue medication teaching, return precautions—status]
• Follow-up: [Clinic/therapy referrals with timing; communication to PCP/outpatient neurologist]

(For missing information, explicitly state what is pending or unknown rather than omitting.)