Pediatric Surgery Consult Note (ED/Inpatient)

Date/Time Evaluated: [Date and time patient evaluated]

Patient: [Full name], [Age], [Weight], [Dosing weight if different]

Location: [ED / Inpatient unit and room]

Historian: [Source(s) of history and any limitations]

Reason for Consult

• Requesting service/clinician: [Service and clinician name]
• Consult question: [Explicit question restated]
• Urgency: [Emergent / Urgent / Routine]
• Time of request: [Date/time consult requested]
• Callback contact: [Name/role and phone/pager]

Consult Summary

One-line summary: [Age] [sex] with [key condition/primary symptom] in the setting of [salient context].

• Impression: [Most likely diagnosis]; Alternatives: [Key differentials]
• Urgency/Operative need: [Emergent / Urgent / Routine]; [Operative intervention required now / not indicated now / pending additional data]
• Disposition recommendation: [Admit to Pediatric Surgery / Admit with Surgery consult / OR now / Observe / Discharge / Transfer] — [Floor / Stepdown / ICU]
• Immediate actions: [NPO status], [IV access/fluids], [Antibiotics if indicated with dose/route/frequency], [Analgesia], [Imaging with timing], [Labs], [Other immediate steps]
• Contingencies: [Findings or time thresholds that should trigger escalation/callback to surgery]

History of Present Illness

[Chief symptom with onset, progression, severity, and timeline. Include pertinent positives and negatives relevant to surgical differential such as peritoneal signs, bilious emesis, obstipation, bleeding, urinary symptoms, or fever. Document prior evaluations and treatments during this episode with response. Include last PO intake with time and current NPO status. Note prior similar episodes or relevant surgical history. For ED consults, include precipitating event; for inpatient consults, summarize hospital course and consult trigger.] (Write as narrative paragraphs with clear chronology. Use direct caregiver quotes sparingly and only when they clarify clinical uncertainty.)

Past History

• Past medical history: [Major comorbidities, congenital anomalies, bleeding disorders] (Include only if relevant to surgical decision-making.)
• Past surgical/anesthesia history: [Prior operations, complications, airway/anesthesia issues]
• Medications: [Current medications, highlighting anticoagulants, steroids, immunosuppressants]
• Allergies: [Allergen and reaction type]
• Birth/developmental history: [Prematurity, NICU course, feeding/respiratory risks] (Include only if relevant.)
• Critical unknowns: [Item unknown that affects surgical planning] — Mitigation: [Steps to address] (Include only if applicable.)

Review of Systems

[Targeted symptoms directly tied to consult question] (Use a focused ROS. If unobtainable due to age or acuity, document why. Omit this section entirely if not performed.)

Objective

Vitals

[T, HR, RR, BP, SpO2 with trends if relevant]; [Hydration indicators as applicable]

Physical Examination

• General: [Appearance, distress level, toxicity, perfusion, interaction]
• Abdomen: [Inspection: distention, scars]; [Palpation: tenderness location, guarding, rebound, peritoneal signs, masses, hernias]
• GU: [Testicular/inguinal findings] (Include only if relevant. Document chaperone presence or patient declination for sensitive exams.)
• Surgical sites/lines/drains/tubes/ostomies: [Incisions, wounds, line types, drain/tube locations and output, stoma description] (Include only if applicable.)
• Other systems: [Airway, cardiac, respiratory, neuro, skin findings relevant to operative risk] (Include only as needed.)
• Deferred exams: [Component and reason deferred] (Include only if applicable.)

Data Reviewed

• Labs: [Test name, key results, date/time] (Include only decision-relevant results.)
• Imaging: [Study, date/time] — Formal read: [Radiology impression]; Surgical interpretation: [Your interpretation if different]
• Microbiology/pathology: [Test, result, date/time] (Include only if applicable.)
• Pending studies: [Study and expected timing] (Include only if applicable.)

Assessment

Synthesis: [Direct answer to consult question with concise justification.]

• [Problem 1]: [Operative now / Potentially operative / Non-operative]. [Supporting features, key differentials, diagnostic uncertainty.]
• [Problem 2]: [Status and operative relevance with supporting rationale.] (Include additional problems only as relevant.)

Plan

(Organize by problem. Use specific, time-bound action items with doses, routes, frequencies, and responsibility assignment.)

[Problem 1]

• [Diagnostic plan: imaging, labs, serial exam interval with escalation criteria]
• [Therapeutic plan: NPO/diet, IVF, antibiotics, analgesia, procedures]
• [Pre-operative readiness if applicable: consent status, guardian availability, NPO timing, anesthesia considerations, blood products]
• [Team responsibilities and timing]

[Problem 2]

• [Action items tailored to problem]

Disposition

[Admit / Discharge / Transfer] to [service and level of care]. Surgery role: [primary / consulting]. [Surgery to continue following / Sign off with return precautions]. (If discharge: include follow-up timeframe and return precautions. If transfer: include acceptance status and stabilization steps.)

Communication

• [Discussion with requesting clinician: name, time, method, key points communicated]
• [Discussion with attending surgeon: name, time, decisions]
• [Coordination with other services: who, what, when] (Include only if applicable.)
• [Family/caregiver discussion: participants, interpreter if used, topics covered, questions addressed, decisions made]

Procedures and Consent

(Include this section only if a procedure was performed or consent was obtained.)

• Consent obtained from: [Patient / Guardian with name and relationship]; [Interpreter used if applicable]
• Discussion: [Risks, benefits, alternatives discussed]
• Chaperone: [Present with name/role / Declined by patient] (For sensitive exams or procedures.)
• Procedure performed: [Name, indication, date/time, location, operator] (Include only if procedure performed.)
• Technique/findings: [Key details, findings, specimens sent] (Include only if procedure performed.)
• Complications: [None / Describe]; Post-procedure status: [Condition] (Include only if procedure performed.)