Acute Care Pediatric Form
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Acute Care Pediatric
Doubles
Chart No.
Name______________________________________DoB ___ /___ /___ Seen with:
Mth.
Fth.
Other__________________
Patient’s
Physical Exam
Abnormalities
(cont’d)
Normal
Abnormal
Circle and describe all abnormal and pertinent normal findings.
1.
Constitutional
Temp._________ Resp.___________ B.P. ______/______
Looks Ill: 1+, 2+, 3+ Hydration
NL
ABN
2.
Head
shape, size, defects
Face
appearance, birthmarks, scars, defects, tender sinuses
3.
Neck
appearance, asymmetry, swelling, masses; thyroid abn.
4.
Eyes
appears to see, swelling, redness, drainage, (clear, purulent); fundi
5.
Ears
appears to hear, shape, size, defects,
a. rtm
red, dull, thickened, mobility, retracted, bulging
fluid (ser., pur.), perforated, scarred, tube (in, out)
b. ltm
red, dull, thickened, mobility, retracted, bulging
Impression
Normal Exam.
fluid (ser., pur.), perforated, scarred, tube (in, out)
c. ext. canal
cerumen, swelling, tenderness, drainage (ser., pur.)
Nose
nasal mucosa, redness, swelling, drainage (mucoid, pur.)
Mouth
lips, mucosa, teeth, gums: redness, swelling, ulcers
Throat
palate, uvula, pharynx: redness, swelling, drainage
a. tonsils
enlarged 1+, 2+, 3+, 4+, exudate, petechiae, scarred
6.
Chest (Breasts)
nipple discharge; redness, swelling, tenderness
7.
Respiratory
(R or L) effort, wheezes, rales, breath sounds, dull
Procedures
Consults, lab/x-rays, special studies, and reports reviewed.
8.
Cardiovascular
p.m.i., pulses, tachycardia, rate, rhythm, murmurs, cyanosis
Immun. Current?
CBC___________________
Pk Flow_______________
9.
Abdomen
liver, spleen, distention, scars, tender, bowel sounds, masses;
Yes
No
Urine__________________
Pulse Ox ______________
10.
Gastrointestinal
hernias, anus: fissures; rectum: masses, blood, trauma
Quick Strep ____________________________
Special Studies_________
11.
Genitalia
discharge, lesions, trauma
Groin
tenderness, hernia, masses
Buttocks
skin: rashes, defects; muscle: tenderness, swelling
12.
Genitourinary
bladder distention; urethra: discharge, defects, trauma
Drug Allergies
Yes
No
13.
Hematologic
petechiae, bruises
Lymphatic
enlarged lymphnodes: neck, axilla, groin, other
14.
Integumentary
hair, nails, skin: rashes, birthmark, defects, infections
Plan/Treatment
Basic instructions given; parent seemed to understand.
15.
Back (spine)
hair tuft, skin dimple, scoliosis, tenderness, tightness
Ed. Handouts
16.
Musculoskeletal
lower extremities: hips, pelvis, knees, ankles, feet
a. muscles
tenderness, swelling, weakness, defects, atrophy
b. bones / joints
range of motion, tender., swelling, fluid, defects
17.
Musculoskeletal
upper extremities: neck, shoulder, elbows, wrists, hands
a. muscles
tenderness, swelling, weakness, defects, atrophy
b. bones / joints
range of motion, stability, tender., swelling, fluid, defects
18.
Neurologic
gait, cranial nerves, DTR's, path. reflexes; sensation
19.
Psychiatric
behavior, alertness, attentiveness, mood
Call:
24 hrs.
48 hrs., prn
Follow-up ______________________
Abnormalities
Disposition:
Home
Referral
Admitted
Condition:
Unchanged
Improved
Stable
Worse
Amount of time spent face to face (when using time based coding)__________________
Provider’s Signature_________________________________________ Date __________________
Acute
Date / Time
Age
Wt / %
Ht / %
Summary
After hours
Follow-up visit
Referral
Care
100-30
Pediatric
Rev. 1/08
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