Pediatrics Consult

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™

Template

Pediatric Consult

Date/Time:
Reason for Consultation:[Brief statement of why the patient was referred or seen]

Patient Identification: [Patient name], [age], [sex], [relevant background or presenting context]

History of Present Illness:
(Begin with the chief complaint and duration. Then provide a chronological, problem-oriented narrative that focuses on the reason for consultation. Group related symptoms into coherent separate paragraphs rather than a single block of text. For each main problem or symptom cluster, explicitly address where available: onset, duration, tempo/progression, location and radiation, quality, severity, aggravating and relieving factors, associated symptoms, and key negatives. Include relevant baseline function, prior episodes, relevant past investigations or imaging, prior treatments and response, and any recent triggers. Comment on relevant risk factors for the presenting problem when available. Summarize functional impact where available.  End with a review of systems related to the presenting problem)

[Paragraph 1]

[Paragraph 2]

[Review of systems specific to the speciality]

Past Medical History:
(hyphenated list)
- [Condition or diagnosis, age at onset, current status]
- [Surgeries or hospitalizations, dates and reasons]

Medications:
(hyphenated list)
- [Medication name, dose, route, frequency]
- [OTC or supplements if applicable]

Allergies:
(hyphenated list)
- [Allergen]: [Type of reaction]
- If none: No known drug allergies (NKDA)

Family History:
(hyphenated list)
- [Relation]: [Relevant condition or health status]

Social History:
(hyphenated list)
- [Living situation (e.g., lives with parents/guardians)]
- [Daycare/school attendance]
- [Parental occupation/environmental exposures]
- [Tobacco smoke exposure or pets at home]

Developmental History:
(hyphenated list)
- [Gross motor milestones: age achieved]
- [Fine motor milestones: age achieved]
- [Language milestones: age achieved]
- [Social/adaptive skills: description]

Growth Parameters:
(hyphenated list)
- Age: [months/years]
- Weight: [kg] (percentile if known)
- Height/length: [cm] (percentile if known)
- Head circumference: [cm] (percentile if known)

Immunizations:
(hyphenated list)
- [Vaccine name]: [Up to date/Date last given]
- [Vaccine name]: [Up to date/Date last given]

Physical Examination:
(hyphenated list)
- Vital signs: HR: [ ], BP: [ ], T: [ ], RR: [ ], O₂ sats: [ ]
- General: [Appearance, behavior, distress level]
- HEENT: [Findings]
- Neck: [Findings]
- Respiratory: [Findings or “Chest clear to auscultation bilaterally”]
- Cardiovascular: [Findings or “Normal S1/S2, no murmurs”]
- Abdomen: [Findings]
- Neurological: [Findings]
- Skin: [Findings]
- Musculoskeletal: [Findings]

Investigations:
(hyphenated list)
- Laboratory: [Test name and result]
- Imaging: [Study and key findings]
- Other studies: [e.g., hearing, vision]

Assessment & Plan:
(Use medical terminology if appropriate. Do not fabricate.)
[One-sentence patient summary including age, sex, and primary diagnosis if not redundant]

#) [Assessment as a numbered item] 
- [Hyphenated list with each corresponding plan item on a new line]