Pediatric Pulmonology Inpatient Progress Note (Primary Pulmonary Service)

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

Author/Service: Pediatric Pulmonology (Primary)

Hospital Day: [Hospital day number]

Location: [Unit/room]

Primary Diagnosis: [Primary admitting diagnosis]

Code Status: [Code status]

One-Liner: [Age, key pulmonary condition, admission reason, current respiratory support with key settings, active therapies with day of treatment if relevant, and trajectory: [improving / stable / worsening]] (Single sentence; update daily.)

Subjective

[Overnight events and interval symptom changes relevant to respiratory status] (Include desaturations, support changes, cough/sputum trends, wheeze, dyspnea, sleep quality. Note airway clearance tolerance, medication tolerance, and family/patient concerns. Keep concise—avoid restating unchanged history. If unable to obtain subjective information, note briefly only when clinically relevant.)

Objective

Vitals: [Temp, HR, RR, BP, SpO2 with oxygen source, weight if relevant]

Respiratory Support: [Current device/mode and key settings (flow, FiO2, pressures as applicable)] | Target SpO2: [range] | 24-hour trend: [brief summary if informative] | Weaning/escalation readiness: [statement with criteria] | Airway clearance: [modality, frequency, tolerance] (per RT flowsheet) (Always include; explicitly update daily.)

Exam: [General appearance and comfort], [work of breathing assessment], [auscultation findings], [interface/trach site condition if applicable], [other pertinent systems only when relevant to respiratory status]

Data: (Include only if results affect decisions; otherwise omit.)

• New today: [Relevant labs, ABG/VBG, imaging, cultures, spirometry/peak flow]
• Pending: [Test] — pending as of [time]
• Reviewed prior: [Pertinent unchanged results if relevant to today's decisions]

Assessment & Plan

(Problem-based format, numbered by acuity. For each problem: 1–3 line assessment of status and trajectory, then bulleted plan. Cross-reference related problems to avoid duplication. Update antibiotic day and respiratory support plan daily.)

1) [Problem name]

[Assessment: clinical status, interpretation, trajectory since yesterday]

• [Respiratory support plan with weaning steps or escalation thresholds]
• [Airway clearance plan if applicable]
• [Pharmacotherapy: agents, doses, duration]
• [Antibiotics if applicable: agent, indication, day #/total, culture targets, monitoring]
• [Diagnostics/monitoring with timing]
• [Contingency plan for deterioration]

(Include only relevant plan items for each problem.)

2) [Additional problem]

[Assessment and plan as above]

(Add or remove problems as needed.)

Discharge Readiness

• Respiratory stability: [met / not met] — [current status vs. criteria]
• Airway clearance home plan: [met / not met] — [equipment, training, tolerance]
• Antibiotic transition: [IV to PO / OPAT / N/A] — [agent, day, total duration]
• Caregiver education: [met / in progress / not met] — [skills covered/remaining]
• Equipment/supplies: [secured / pending] — [brief details]
• Follow-up: [scheduled / pending] — [clinic, timeframe]
• Barriers: [none / describe] — [transportation, social, other]
• Anticipated discharge: [date / TBD]

(Update daily.)