Pediatric Surgery Daily Progress Note (Inpatient)

Date/Time: [date and time]
Author: [role] | Attending: [attending name]
Patient: [name, MRN, unit/room]
Age/Sex: [age, sex] | Weight (kg): [weight]
Hospital Day: [number] | POD: [number] (Only include POD if post-operative)
Primary Diagnosis: [diagnosis]
Procedure/Date: [procedure and date] (Only include if post-operative)
Allergies: [allergy list or "NKDA"]

One-Liner: [Single-sentence summary: age, sex, diagnosis, procedure/POD or nonoperative status, admission reason, current status]

Interval/Subjective

[Overnight events and interval changes] (State "No acute events overnight" if none. Note what is unverified if documentation incomplete.)

• [Pain and comfort status with response to interventions]
• [Diet/feeding tolerance; nausea or emesis if present]
• [GI function: flatus, stool; NG/ostomy output if applicable]
• [Caregiver concerns or questions]

Objective

Vitals: [Trend summary and clinically significant values: Tmax, hemodynamics, O2 support] (Do not list all raw vitals.)

I/O: [24h totals; UOP in mL/kg/hr if relevant; drain outputs by device with character]

Lines/Drains/Tubes: [Each device: location, output/status, site condition, necessity] (State "None" if no devices.)

Labs: [Values that changed management or are being trended with direction, e.g., "WBC 18→14"] (State "Labs stable" or "No new labs" if none relevant.)

Imaging/Micro: [New or pending studies with succinct interpretation] (State "No new imaging/cultures" if none.)

Assessment & Plan

(Organize by clinical priority, highest acuity first. For each problem: 1–3 sentence assessment, then plan as brief bullets.)

[Problem 1]: [Diagnosis/clinical issue]

[Current status, response to therapy, trajectory]

• [Plan items]
• [Studies/consults with timing]
• [Monitoring parameters and contingency criteria]

[Problem 2]: [Diagnosis/clinical issue]

[Assessment] (Include additional problems as needed, ordered by acuity.)

• [Plan items]

Safety & Supportive Care

• Antibiotics: [indication, agent(s), day of therapy, stop criteria/duration] (State "No antibiotics" if none.)
• Pain: [current regimen, pain score/assessment, adjustment plan; bowel regimen if on opioids]
• Diet/Nutrition: [current order, tolerance, advancement criteria; IVF status]
• Lines/Drains/Tubes: [necessity for each device and removal criteria]
• VTE Prophylaxis: [mechanical / pharmacologic / not indicated] (Include rationale or contraindication.)

Disposition: [Anticipated discharge timing and barriers; explicit discharge criteria: tolerating diet, pain controlled on PO, afebrile, drains removed or caregiver trained, follow-up scheduled]