DOCUMENTATION
Admission Note (Template)
Paediatric History and Physical Examination (as previous), and:
INVESTIGATIONS
• Blood work: CBC, electrolytes, glucose, renal function, liver function
• Microbiology: blood, urine, CSF, nasal, stool cultures
• Imaging: x‐ray, ultrasounds, CT, MRI
• Pathology: if relevant
IMPRESSION/ASSESSMENT (IMP)
This is a (year old) (sex) [who is previously healthy] or [with a history of
XYZ] presenting with (brief summary of pertinent positive/ negative
symptoms on history, signs on physical examination and relevant
investigations) with a most likely diagnosis of _____________.
DIFFERENTIAL DIAGNOSIS (DDX)
May chose to use broad categories by system or process when considering
specific diagnoses (i.e., use of VITAMINS ACD acronym)
Vascular, Infectious/Inflammatory, Traumatic/Toxin, Autoimmune/
Acquired, Metabolic/Medication, Iatrogenic/Idiopathic, Neoplastic, Social,
Allergic, Congenital, Degenerative, Endocrine
MANAGEMENT PLAN/ADMISSION ORDERS (PLAN)
• Admit: Admit to (your service) under (your consultant today).
• Diagnosis: This is what you suspect they have. (e.g., Asthma)
• Diet: DAT (diet as tolerated) NPO (nothing per os/by mouth; if going
for surgery or procedures), Breast feed ad lib, Formula, Tube feeds
(NG‐tube, G‐tube, GJ‐tube)
• Activity: AAT (Activity as Tolerated), bedrest
• Vital Signs: VS (Vital Signs q8‐12h = HR, RR, BP, O2 sat, Temp), VS
q4h (if particularly sick patient requiring more frequent vitals),
Special parameters (e.g., Neurological vitals)
• Monitoring: ECG, oxygen saturation, Ins & Outs, daily weights
• Investigations
o Bloodwork (Hematology, Biochemistry)
o Microbiology
o Imaging
o Consults
• Drugs
o Past: Medication Reconciliation – all regular medications (may not
need all; e.g., no need for previous PO antibiotics if starting IV)
o Present: what does patient need now
o Future: anticipate what patient may need; e.g., fever, nausea, pain,
stools

Progress Note (Template)
(Service) Progress Note
Date, Time
ID
Age, sex with a history of (non‐active/chronic issues) admitted with (list
active/acute issues for why the patient is admitted). Could also include a
list of recent events that occurred since the most recent note.
SUBJECTIVE
• How was patient overnight, how they feel that day, any new concerns
from the patient/parent
• What has changed since the previous note? Does the patient have any
new symptoms? Any pain? How is the patient coping with the active
symptoms, progression, better/worse.
• Ask the parents and patient’s nurse: behaviour, activity, sleep,
appetite, in and outs.
OBJECTIVE
Vitals: HR, BP, RR, SaO2, Temp, daily weight, pain
I/O: Inputs (Diet, IVF), Output (U/O, BM/Diarrhea, Vx, Drains), fluid
balance
General: what the patient is doing, appearance, behaviour, cognition,
cooperation, disposition
P/E: focused physical exam of system involved plus CVS, RESP, ABDO as it
is common for hospitalized patients to develop problems in these regions.
INVESTIGATIONS
New lab results, imaging or diagnostic tests/ interventions and relevant
results still pending
MEDS
Reviewed daily regarding changes such as new/held/discontinued/
restarted (e.g. Ampicillin day 2/10)
IMPRESSION/ASSESSMENT (IMP)
Summarize what the new findings mean, what progress is being made.
Stable vs. Unstable? Improved vs. Worsened? Waiting investigations/
consult? Differential diagnosis if anything has been ruled in/out?
PLAN (P)
1. Issue (1) 􀃆 plan (e.g., UTI on Day 2 of Empiric Abx, likely 14 day
course required, await urine C&S)
2. Issue (2) 􀃆 plan
3. Issue (3) 􀃆 plan
4. Disposition – plans for home, transfer

Discharge Summary (Template)
Check patient’s name, medical record number, date of birth, date of
admission, date of discharge, most responsible physician (MRP), referring
physician name.
FINAL DISCHARGE DIAGNOSIS
• Often only one diagnosis is responsible for admission (i.e. vasoocclusive
crisis, asthma exacerbation, bronchiolitis or Kawasaki
Disease)
• However sometimes there are associated diagnoses (i.e. Gastroenteritis
with dehydration and renal failure, osteomyelitis with bacteremia)
OTHER DIAGNOSIS (nonactive
or those affecting hospital stay)
Other diagnoses requiring treatment during hospitalization or underlying
medical diagnoses existing prior to admission
HISTORY OF PRESENTING ILLNESS
(Name) is a (year old) (sex) [who is previously healthy] or [with a past
medical history of XYZ] who presented with (X) day history of (summary
of pertinent positive and negative symptoms on history and other
relevant/contributing elements of birth history, development, past
investigations/treatment, immunizations as appropriate). Significant
signs on initial physical examination included__________. In the ER,
management included _______________.
COURSE IN HOSPITAL
(Name) was admitted to (name of service and ward)… [and describe
briefly the events and progression of illness while in hospital including
results and management. If the child has multiple medical issues, this
section can be done by system (cardiovascular, respiratory, fluids and
nutrition, ID, CNS, etc). List significant/complex investigations (with
results) under a separate heading.
At discharge, describe current symptoms, physical examination and
pending results.
DISCHARGE MEDICATIONS
Drug name, dose, route, dosing interval frequency, and duration
DISCHARGE GENERAL INSTRUCTIONS AND FOLLOWUP
All discharge summaries must include at least 3 essential elements
1. Discharge treatment plan including duration
2. Follow‐up with primary care physician in… (specify a reasonable time
frame)
3. Seek medical attention if…
May include other referrals and follow‐up appointments as necessary,
pending investigations and other community resources

Handover
At Sick Kids, IPASS
is the format used for handover.
• Illness severity
o Stable / Watcher / Unstable
• Patient Summary
o Summary statement
o Events leading up to admission
o Hospital course
o On‐going assessment
o Plan
• Action Items
o To‐do list
o Timeline and ownership
• Situational awareness and contingency planning
o Know what’s going on
o Plan for what might happen
• Synthesis by receiver
o Receiver summarizes what was heard
o Asks questions
o Restates key actions/to do items