Date:
Patient: [Patient Name], [Age], [Medical Record Number]
Attending: [Physician Name]
I. Subjective
Information obtained from parents/guardians or chart review:
Reason for admission to PICU
History of present illness (onset, progression of symptoms)
Past medical history (including surgeries, chronic conditions)
Medications and allergies
Social history (prenatal history, birth history, developmental milestones)
II. Objective
Vital signs (temperature, heart rate, respiratory rate, blood pressure, oxygen saturation)
Physical exam findings (general, neurological, respiratory, cardiovascular, abdominal, etc.)
Height, weight, BMI (if possible)
Laboratory results (blood gas, CBC, electrolytes, inflammatory markers, etc.)
Imaging studies (chest X-ray, head CT scan, etc.)
Fluid balance (intake and output)
Respiratory support details (ventilator settings, FiO2, etc.)
Level of sedation/pain control
III. Assessment
Concise summary of the patient’s current condition, including:
Primary diagnosis or working diagnosis
Severity of illness (e.g., using scores like PRISM III)
Identification of potential complications
Response to current interventions
IV. Plan
Specific treatment plan addressing:
Respiratory management (ventilator settings, oxygen therapy)
Fluid management and electrolytes
Nutrition (enteral or parenteral)
Pain management and sedation
Medication administration (including antibiotics, antifungals, etc.)
Imaging or other studies as needed
Consultation with specialists (e.g., cardiologist, surgeon)
Family communication and decision making
V. Progress
Briefly summarize the patient’s progress over the past 24 hours:
Changes in vital signs and clinical status
Response to treatments
New developments
VI. Prognosis
Discuss the anticipated course of illness with guarded language:
Potential for improvement or deterioration
Risk of complications
VII. Follow-up
Plan for the next 24 hours:
Frequency of assessments
Monitoring parameters
Anticipated interventions
Next steps in the care plan
VIII. Notes
Document any additional information relevant to the patient’s care
Disclaimer: This is a template and may need to be modified based on the individual patient’s presentation and specific critical illness.
Additional Information:
Consider including specific sections for procedures performed or planned procedures.
You may also want to document goals of care discussions with the family.
Include any specific risk factors or social determinants of health relevant to the patient’s condition.
Remember: This information is for educational purposes only and should not be interpreted as medical advice. Please consult with a qualified healthcare professional for diagnosis and treatment of critically ill children.