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Pediatric Emergency Medicine Physician

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Pediatric Emergency Note

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Finished note

Example — generated by Notat from a sample visit

Reason for visit:
Three-day history of fever, runny nose, and reduced appetite. Drinking fluids and passing urine normally.

Assessment:
Likely uncomplicated viral upper respiratory infection. Child is alert and clinically stable today.

Plan:
Supportive care and fluid intake advised. Parent given clear safety-netting for breathing difficulty, dehydration, or persistent fever.

Clinical documentation:
Relevant symptoms, meaningful negatives, assessment, and follow-up advice were captured from the sample visit and organised into the selected template.

FactsContext™

symptoms

Symptoms: Fever, runny nose, and reduced appetite for three days

history of present illness

Hydration: Drinking fluids and passing urine normally

Visit focus: The main concern, timeline, and functional impact were identified from the conversation.

assessment

Working diagnosis: Likely uncomplicated viral upper respiratory infection

plan

Safety-netting: Seek review for breathing difficulty, dehydration, or persistent fever

Safety-netting: Follow-up triggers and urgent return precautions were documented as part of the plan.

denials of symptoms

Denies: Relevant denials: Relevant red flags and absent symptoms were retained to support the documented assessment.

Template

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]

Shared by

PN

Dr. Priya Nair

Pediatrician, Singapore

How it works in Notat

Add this template to your library, record the visit as usual, and Notat drafts the note in this exact structure from the extracted clinical facts. You review, edit, and sign.

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