Paeds clerking
PAU clerking
Age & sex
Seen with mum / dad
PC:
HPC:
(prompts:
GI/GU - E+D, NVDC/CIBH/nappies, PU
Cough/colds, fevers, rash,
Other sickness in family, recent travel, pets)
PMH:
DHx:
Imms:
Allergies:
FHx:
SHx: Lives at home with
Social worker
O/E:
Alert/Lethargic, bright/irritable
Able to mobilise to examination room independently
Pink, well perfused, CRT <2s
Ears:
Neck: cervical LN
Throat:
Chest:
HS normal
Abdo SNT
Obs: PEWS
Urinalysis:
Other Ix:
Imp: ?
Plan
Paeds WR proforma
WR Cons / SpR Dr
Age & sex
1. Diagnoses / current issues
2.
Obs: PEWS
Bloods :
On review
DRAFT / PT NOT SEEN YET
Mum / dad at bed space
O/E
Alert
Warm, well perfused
work of breathing / No visible respiratory distress
Chest - ; HS
Abdo
Imp:
Plan
Paeds discharge
Name is a blank-year-old girl who presented to the Paediatric Emergency Department / Assessment Unit of Heartlands Hospital on DATE with (symptoms). The history and clinical examination were in keeping with xxx. [Mx] She was admitted for observation and supportive care. As she remains clinically stable, we are now discharging her.
Name is a blank-year-old boy who presented to the Paediatric Emergency Department / Assessment Unit of Heartlands Hospital on DATE with (symptoms). The history and clinical examination was in keeping with xxx. [Mx] He was admitted for observation and supportive care. As he remains clinically stable, we are now discharging him.
Disclaimers to add at end of discharge letters
Kindly note that this discharge summary has been prepared based on documentation by my colleagues; this doctor has not been personally involved in the management of this patient.
Kindly note that this discharge summary has been prepared by a colleague; this doctor has not been personally involved in the management of this patient.
Safety netting/info given to parents: www.what0-18.nhs.uk for more information
Please bring your child back to PAU in the next 48 hours or to your nearest Paediatric Emergency Department thereafter if you have concerns regarding your child’s recovery (for example, copy&paste).
Resp: if they are breathing very fast or have breathing that stops or pauses for more than 10 seconds, if they have very harsh breathing noises, if they get less alert and responsive, if they have high fevers (>38.5’C) that do not go down with paracetamol or ibuprofen
GI (D&V): if there is blood in the vomit or stools, if they are struggling with breathing, if they are less alert and responsive, if they have a rash that does not disappear on pressure (non-blanching), if they have high fevers (>38.5’C) that do not go down with paracetamol or ibuprofen
Febcon: if they have a fit that lasts longer than 5 minutes, have one fit after another without being awake in between, become injured during a fitting episode.
Please ensure that your child completes the course of antibiotics that has been given to them.
Information given to GP:
Dear colleague, kindly note the recent admission of this patient.