Pediatric Pulmonology Discharge Summary (Primary Pulmonary Service)

Patient Name: [Patient full name]   MRN: [Medical record number]   DOB: [DOB (MM/DD/YYYY)]   Age/Sex: [Age] / [Sex]   Admission Date: [MM/DD/YYYY]   Discharge Date: [MM/DD/YYYY]   Length of Stay: [X days]   Attending Physician: [Name, credentials]   Discharging Clinician: [Name, credentials]   PCP: [Name, practice]   Primary Language: [Language]   Allergies: [NKDA / list allergies and reactions]   Discharge Disposition: [Home / Home with services / Acute rehab / SNF / Other]

Brief Synopsis

[Executive summary in 3–6 sentences: pulmonary-focused reason for hospitalization; principal pulmonary diagnosis and major inpatient interventions; respiratory support at discharge with explicit device and settings; discharge condition; most important follow-up and any pending tests.]

Diagnoses

Principal Discharge Diagnosis: [Single primary diagnosis]

Secondary Diagnoses/Comorbidities: [Relevant secondary diagnoses and chronic pulmonary conditions with severity or dependence status as applicable—e.g., asthma severity, BPD, CF/bronchiectasis, trach/vent dependence, OSA, pulmonary hypertension, aspiration risk]

Reason for Admission: [Chief symptoms and clinical context triggering admission; baseline respiratory status prior to illness if known—room air vs oxygen, nocturnal support, home vent settings, usual inhaled regimen] (If baseline unknown, state "Baseline respiratory status unknown.")

Hospital Course

(Organize by problem with pulmonary problems listed first. For each problem: presentation and diagnostic impression; key diagnostics with meaningful positives/negatives only; therapies and interventions with dates/durations; clinical response and status at discharge; discharge plan. Use dates for key transitions. State specific settings, doses, and durations—avoid vague terms.)

[Pulmonary Problem 1]

[Narrative course including: respiratory support trajectory from baseline through maximum support to weaning milestones to discharge; bronchodilator and steroid courses with agent, route, total duration, days remaining; antibiotics/antivirals with indication, supporting cultures/diagnostics, total duration; airway clearance regimen changes; oxygenation targets; addressed triggers/risk factors such as smoke exposure, aspiration risk, equipment issues, adherence barriers]

[Pulmonary Problem 2]

[Narrative course as above] (Add additional pulmonary problems as needed.)

[Non-Pulmonary Problem]

[Narrative course with diagnostics, therapies, and ongoing needs affecting respiratory care or overall safety] (Include additional non-pulmonary problems as needed.)

Respiratory Support at Discharge

(This section is required for every patient.)

• Device/Modality and Settings: [Room air / Low-flow nasal cannula / HFNC / CPAP / BiPAP / Invasive ventilator] at [specific settings: flow (L/min), FiO2 (%), pressures (cm H2O), vent mode/rate/Vt/PEEP as applicable] (If room air, state explicitly "Room air without supplemental oxygen.")
• Use Schedule: [Continuous / Sleep only / During illness or exertion / PRN with specific criteria]
• Target SpO2 and Monitoring: Target SpO2 [X–Y%]; monitoring via [continuous pulse oximetry / spot checks with frequency]
• Humidification: [Required—HME vs heated humidification with settings / Not required]
• Tracheostomy: (Include if applicable.) [Trach type and size], [cuffed / uncuffed], suctioning [frequency/criteria and catheter size], HME/humidification [details], speaking valve [use parameters and tolerance if applicable]
• Baseline Comparison: [Baseline respiratory support prior to admission if different from discharge] (If unknown, state "Baseline respiratory support unknown.")

Airway Clearance & Inhaled Therapies at Discharge

(Include if applicable; omit section if no airway clearance or inhaled therapies prescribed.)

• Airway Clearance: [CPT / Vest / PEP / Oscillatory PEP / Cough assist] at [frequency per day, session duration, device settings]
• Nebulized/Inhaled Medications: [Medication, concentration/strength, device (nebulizer / MDI / DPI), dose, frequency, indication] (Distinguish controller vs rescue; note spacer use.)
• Education Status: [Inhaler/spacer/nebulizer technique education and caregiver competency verification: completed / pending]

Key Results

(Include results that impact ongoing care. If no pertinent studies obtained, state "No key diagnostic studies obtained during admission" or omit section.)

• Microbiology/Cultures: [Specimen source, collection date, organism(s) and susceptibilities, interpretation (colonization vs infection), antibiotic linkage] (Note pending cultures with expected finalization date.)
• Imaging: [Date, modality, impression, follow-up imaging needed and timing]
• PFTs/Spirometry: [Date, FEV1, FVC, FEV1/FVC, bronchodilator response, interpretation]
• Other Respiratory Studies: [Sleep study with AHI/SpO2 nadir; bronchoscopy findings; blood gases driving respiratory decisions]

Procedures & Consultations

(Omit section if none.)

• Procedures: [Date, procedure name, key findings, complications]
• Consultations: [Service, recommendations persisting after discharge—medication changes, follow-up needs, equipment requirements]

Discharge Condition

Overall Condition: [Improved / Stable / Guarded]

• Respiratory Status: [Work of breathing, breath sounds, cough effectiveness, suctioning needs, tolerance of discharge support]
• Vital Signs: [Temp, HR, RR, BP, SpO2 on current support with settings specified]
• Focused Exam: [Pulmonary exam highlights and other relevant findings]
• Discharge Weight: [Weight in kg with date]

Discharge Medications

(For each medication: generic name, dose with mg/kg if weight-based, route, frequency, indication, duration/stop date for antibiotics and steroids. For respiratory medications: steroid taper schedule or remaining days; antibiotic total duration and inpatient days completed; inhaled controller strength and device; rescue bronchodilator PRN thresholds and maximum frequency. Include special instructions—spacer use, mouth rinse after ICS. If no medications, state explicitly and clarify whether to resume home medications.)

New

• [Medication] — [Dose including mg/kg if relevant], [route], [frequency], [indication], [duration/stop date if time-limited], [special instructions]

Changed

• [Medication] — [Change detail: dose/formulation/frequency], [new dosing], [indication], [rationale]

Continued (Unchanged)

• [Medication] — [Dose], [route], [frequency], [indication]

Stopped

• [Medication] — [Reason for discontinuation]

Discharge Devices & Equipment

(If no devices or equipment required, state "No home respiratory devices or equipment required at discharge." and omit the list below.)

• Oxygen: [Concentrator / Portable tanks], [flow rate and delivery interface], backup supply [arranged / not arranged]
• Ventilation: [Ventilator / CPAP / BiPAP], [model], [settings], [interface—mask type or trach connection], [humidification]
• Tracheostomy/Suction: [Trach type/size, cuffed/uncuffed], spare trach sizes [specified], suction machine and catheter size, care supplies
• Nebulizer/Compressor: [Model and supplies provided]
• Airway Clearance Devices: [Vest / PEP / Cough assist] with [settings and frequency]
• Pulse Oximeter: [Continuous vs spot checks, thresholds prompting action]
• DME Company: [Name and contact], delivery [confirmed / pending / scheduled date]
• Home Services: [Home nursing / RT services] at [frequency]; caregiver training status [completed / pending with topics covered]

Discharge Instructions Summary

• Education Provided: [Diagnosis overview; medication administration training including inhaler/spacer/nebulizer technique; oxygen and fire safety; device troubleshooting]
• Return Precautions: [Increased work of breathing; hypoxemia below specified threshold despite prescribed support; cyanosis; apnea; inability to tolerate feeds; altered mental status; device malfunction not correctable at home; other condition-specific thresholds]
• Activity/School/Daycare: [Restrictions, PE exemptions, mask use, availability of rescue medications, asthma action plan provided]

Follow-Up Plan

Scheduled Follow-Up:

• Pulmonology: [Clinic/program], [timeframe or scheduled date], [purpose; bring equipment or logs if needed]
• PCP: [Timeframe], [goals—transition of care visit, medication review, weight check, action plan reinforcement]
• Other Subspecialties: [ENT / Cardiology / Sleep medicine / SLP-Feeding therapy / Other] at [timeframe] for [focus]

Pending Results: (This subsection is mandatory.)

• [Test name], [date obtained], [current status], [responsible clinician/service for follow-up], [how and when results will be communicated to family and PCP]
• (If no pending items, state: "No pending tests or studies at discharge.")

Planned Outpatient Testing: (Omit if none.)

• [Test/study], [timing], [ordering service], [purpose]

(Do not infer discharge respiratory support, medications, pending results, or home equipment—document only what is explicitly known. Use exact dates and explicit device settings with standard units. If information is unavailable, state "Unknown" rather than omitting.)