Pediatric sick visit template

Pediatric Sick Visit Note

Chief Complaint
- Caregiver/patient stated reason for visit.

HPI
- Onset, duration, fever pattern (method/max temp), associated symptoms, and trajectory.
- Intake/urine output, activity level, work of breathing, oral intake, vomiting/diarrhea, rash, ear pain, and sleep.
- Exposures, daycare/school attendance, sick contacts, recent travel, and prior episodes.
- Treatments tried (antipyretics with dosing if known) and response.
- Immunization status relevant to presenting illness when discussed.

Pertinent History
- PMH (including prematurity, asthma, immunocompromise), medications, allergies.
- Preferred pharmacy and caregiver decision-makers present.

Exam
- Vital signs including weight when relevant; general appearance (toxic vs nontoxic), hydration, and work of breathing.
- Focused exam by system; otoscopy/throat/lungs/abdomen/skin as performed.
- Document critical negatives influencing MDM.

Testing
- Point-of-care or ordered tests (rapid strep, flu/COVID, UA, CXR, etc.) with results/interpretation.

Assessment / MDM
- Clinical impression and differential with age-specific reasoning.
- Criteria for home management vs higher level of care.

Plan
- Medications with weight-based dosing counseling as discussed.
- Supportive care, isolation/return-to-daycare/school guidance.
- Explicit return precautions (e.g., dehydration signs, respiratory distress, lethargy, fever duration thresholds).
- Follow-up timing.