Pediatric Surgery Admission H&P

Date/Time of Encounter: [Date and time]

Service: [Pediatric Surgery]

Attending of Record: [Attending name]

Patient Location: [ED / PICU / NICU / floor]

Admission Type: [elective / urgent / emergent]

Planned Procedure: [Procedure name with laterality/level when relevant]

Anticipated Timing: [OR today / OR tomorrow AM / date-time window]

Historian/Source: [patient / parent-guardian / medical records / EMS / outside facility] (Include interpreter name/ID and language if used.)

Limitations: [Limitations to history and/or exam] (Only include if limited; briefly explain why and document alternative sources used.)

Safety Summary: Age: [Age in years; add months for infants] | Weight: [kg] (If unknown, document reason and mitigation plan.) | Allergies: [List with reaction types, or NKDA verified with historian] (Emphasize drug and latex; if unknown, document reason and mitigation plan.) | Key Devices: [central line / ETT / trach / VP shunt / ostomy / G-tube / drains / none] | Primary Surgical Problem: [Concise phrase]

Chief Complaint / Reason for Admission

[One-line reason for presentation/admission] (If transferred, include reason for transfer and key timepoints.)

History of Present Illness

[Narrative anchor sentence including age, relevant PMH, and presenting problem. Timeline with onset, progression, current severity, and context. Pertinent associated symptoms and surgically relevant negatives actually assessed. Prior care and treatments received (antibiotics, fluids, analgesia, procedures) with doses/times if available. Key objective findings to date (vitals trends, labs, imaging) with source attribution for outside studies. Working diagnosis and indication for surgery or admission. Clinical stability assessment (hemodynamics, respiratory status, hydration).] (Use absolute dates/times for critical timepoints such as last oral intake and antibiotic start. For anticipated surgery, include last oral intake with type/time and current NPO status. Incorporate pediatric-specific elements when relevant: recent URI/respiratory symptoms; feeding/PO tolerance, emesis, stool/urine patterns for GI/GU pathology; birth history/prematurity/congenital anomalies for infants affecting surgical or anesthetic risk. If any information is unavailable, document what is unknown, why, and mitigation efforts.)

Past Medical History

• [Major chronic conditions affecting perioperative risk: cardiac, pulmonary (asthma, OSA, chronic lung disease), neuromuscular, seizure disorder, diabetes, bleeding disorders, sickle cell disease, immunodeficiency, relevant congenital anomalies or syndromes]
• [For infants when relevant: prematurity (gestational age), NICU course, apnea history]

(Include only conditions relevant to perioperative risk; omit non-contributory imported lists.)

Past Surgical/Anesthesia History

• [Prior operations (especially abdominal, airway, vascular access) with dates if available]
• [Anesthesia exposures and any adverse reactions (difficult intubation, PONV, malignant hyperthermia concern, significant bleeding)]
• [Surgical complications (adhesions, infections, poor wound healing)]
• [Family history of malignant hyperthermia or anesthesia complications]

Medications

• [Home medications with dose, route, frequency; note last taken when relevant to perioperative timing]
• [OTC/herbal agents affecting bleeding or sedation]
• [Chronic steroids/immunosuppressants] (Note for stress-dose consideration.)

Allergies

• [Medication allergies with reaction type; include latex and adhesive sensitivities when relevant]
• [NKDA verified with historian / unknown with reason and mitigation plan]

Family History

• [Bleeding disorders, thrombophilia, malignant hyperthermia, heritable conditions relevant to presenting problem]

(Include only when it affects perioperative risk. Document noncontributory only if specifically assessed.)

Social History

• Custody/Consent: [Legal guardian and who can consent]
• Living Situation: [Caregiver support relevant to discharge planning]
• Adolescent Confidential Assessment: [Substance use, pregnancy risk, safety] (Include only when relevant and permissible; label as confidential.)

Review of Systems

• Constitutional: [Fever/chills, weight change]
• Respiratory: [Cough, recent URI symptoms, wheeze]
• Cardiovascular: [Syncope, exercise tolerance]
• GI/GU: [Pain, emesis, stool/urine changes]
• Neurologic: [Seizures, baseline mental status]
• Hematologic: [Easy bruising/bleeding]

(Focused ROS driven by surgical complaint and anesthetic risk. If ROS cannot be obtained due to age or acuity, document why and what source substitution was used.)

Physical Examination

• Vitals: [Most recent set with units]
• General: [Appearance, distress level, hydration, perfusion]
• HEENT/Airway: [Mouth opening, neck mobility, mucous membranes, airway features]
• Cardiovascular: [Rate, rhythm, perfusion, murmurs]
• Respiratory: [Work of breathing, breath sounds]
• Abdomen: [Distension, tenderness location, guarding/rebound, masses, hernias, scars, stomas]
• GU: [Testicular/inguinal/perineal findings as indicated]
• Skin: [Surgical site, rash, trauma findings]
• Neuro: [Mental status, focal deficits]
• Procedure-Site Specific: [Laterality, neurovascular status, local findings]

(Document only what was actually examined. Do not autopopulate normal findings that were not assessed.)

Diagnostics Reviewed

• Laboratory: [Key values/abnormalities with trends; note date/time and source]
• Imaging: [Modality, impression, key findings; note outside vs in-house and date]
• Microbiology: [Cultures/tests and results]
• Prior Operative/Pathology: [Relevant summaries]
• Consults: [Services involved and key recommendations]
• Pending: [Pending studies and interim decision-making]

Assessment

[Primary surgical diagnosis with severity/complications (perforation, sepsis, obstruction, ischemia). Differential diagnosis when uncertainty exists. Comorbidities impacting perioperative risk. Clinical risk framing (aspiration risk, respiratory compromise, dehydration). Stability status and level of care (stable vs unstable; ICU vs floor).] (Keep concise; do not introduce new subjective data.)

Plan

Primary Surgical Problem

• Procedure/Approach: [Planned procedure and approach: open / laparoscopic / non-operative]
• Urgency: [emergent / urgent / semi-urgent / elective]
• Pre-op Steps: [NPO status; IV fluids; antibiotic prophylaxis/therapy with agent and timing; labs/imaging to obtain; type & screen/crossmatch needs; early anesthesia consult if risk factors present]
• Non-operative Plan: [Criteria for intervention and monitoring plan] (Include only if non-operative management.)

Consent Status

• Legal Authority: [parent / guardian / court order / emancipated minor]
• Consent: [obtained / pending / unable—reason]
• Scope: [procedure / anesthesia / blood products]
• Interpreter: [Language and interpreter ID] (Include only if used.)
• Assent: [obtained / attempted / deferred / not applicable]
• Emergency Exception: [Necessity documented; efforts to reach guardian] (Include only if applicable.)

Perioperative Management

• NPO: [Last intake type/time; fasting plan]
• Antibiotics: [Agent, indication, timing]
• VTE Prophylaxis: [Approach and contraindications]
• Pain Plan: [Multimodal strategy; regional anesthesia considerations]
• Antiemetics: [Plan] (Include if high risk.)
• Glycemic Management: [Plan] (Include if diabetic.)
• Stress-Dose Steroids: [Plan] (Include if chronically steroid-exposed.)
• Lines/Tubes: [Anticipated lines/tubes and indications]

Active Comorbidities

• [Condition]: [Management plan and subspecialty input]

(Include only conditions requiring specific perioperative management.)

Fluids/Electrolytes/Nutrition

• Hydration: [Assessment and IV fluid plan]
• Electrolytes: [Abnormalities and repletion plan]
• Nutrition: [NPO vs diet advancement; TPN consideration if prolonged NPO expected]

Disposition and Anticipated Course

• Postoperative Location: [floor / ICU]
• Monitoring Needs: [Apnea monitoring for infants, cardiorespiratory monitoring with OSA/opioids, etc.]
• Devices/Drains/Wound Care: [Anticipated needs]
• Expected LOS: [Estimate]
• Discharge Criteria: [Pain control, diet tolerance, afebrile, ambulating, caregiver teaching]
• Follow-up: [Timing and service/clinic]

Communication

[Family/patient updated on plan; questions addressed; coordinating service identified if multiple teams involved]

Author: [Name, credentials, role, contact]