Pediatric Emergency Note

Template structure

This is the structure Notat follows when it writes the note from the visit — you never fill it in by hand.

Pediatric Emergency Medicine Note

Chief Complaint:
[Chief complaint as stated by patient/parent]

History of Present Illness:
[Chronological description of presenting symptoms, including onset, duration, severity, associated symptoms, and any interventions tried. Include relevant exposures, sick contacts, and recent travel if applicable.]

Past Medical History:
(hyphenated list)
- [Chronic illnesses]
- [Previous hospitalizations or surgeries]
- [Immunization status]

Medications:
(hyphenated list)
- [Medication name, dose, route, frequency]

Allergies:
(hyphenated list)
- [Drug, food, environmental allergies]

Family History:
(hyphenated list)
- [Relevant family medical conditions]

Social History:
(hyphenated list)
- [Home environment]
- [School/Daycare attendance]
- [Tobacco exposure]
- [Other relevant social factors]

Review of Systems:
(hyphenated list)
- [General: fever, weight loss, fatigue]
- [HEENT: headache, sore throat, ear pain, nasal congestion]
- [Respiratory: cough, shortness of breath, wheezing]
- [Cardiac: chest pain, palpitations]
- [GI: vomiting, diarrhea, abdominal pain]
- [GU: dysuria, frequency, hematuria]
- [Skin: rash, bruising]
- [Neuro: seizures, weakness, altered mental status]
- [Musculoskeletal: joint pain, swelling]
- [Other relevant systems]

Physical Examination:
(hyphenated list)
- [Vital signs with units in one line] (e.g., HR: #, BP: #, T: #, RR: #, O2 sats: #%)
- [General appearance]
- [HEENT: findings]
- [Neck: findings]
- [Respiratory: findings]
- [Cardiac: findings]
- [Abdomen: findings]
- [Genitourinary: findings]
- [Skin: findings]
- [Neurological: findings]
- [Musculoskeletal: findings]
- [Other relevant exam findings]

Investigations:
(hyphenated list)
- [Lab results with units]
- [Imaging results]
- [Other diagnostic tests]

Assessment:
(hyphenated list)
- [Primary diagnosis]
- [Differential diagnosis if applicable]
- [Brief summary of reasoning]

Plan:
(hyphenated list)
- [Investigations planned or pending]
- [Medications administered or prescribed]
- [Procedures performed]
- [Consultations requested]
- [Counselling provided]
- [Disposition (admit, discharge, observe)]
- [Follow up plan]
- [Return precautions]