Pediatric Database
In evaluating any child admitted to the hospital, there is a great deal of important information that must be obtained. By using a standardized format to organize patient data, students and physicians can readily collect and process this information, and more efficiently arrive at a diagnosis, assessment and treatment plan for their patients. Students should use the following format for their inpatient pediatric write-ups. Related information can also be found in the Skills section of the Student Curriculum Guide.
Format for
Pediatric Inpatient Write-Ups:
Date, Time, Patient Name, MCG
Hospital #: Referring Physician and
Primary Care Physician: Informant:
(Reliability) Chief Complaint: History of Present Illness: (Include current medications) Past Medical History: (Use
as appropriate for age)
Social History: (Environment in which the child lives) Family History: (Draw Family Tree) Review of Systems:
(Positives and
Pertinent Negatives) Physical
Examination:
Assessment: (List by Problem #) Plan:
(Use Problem #
listed under Assessment)
Discussion: (Cite at least one reference from the literature) |
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