Note formats · Pediatrics
Pediatric Consult Note Template for Sick Visits
Pediatric sick visit or general consult. Notermed's built-in Pediatrics: General Consult Note produces the sections below from what is said during the visit. You read the draft, change anything you want changed, and sign it. Until you sign it, it is a draft and outside the record.
- Sections
- 8, in the note's own order
- Specialty
- Pediatrics
- Unsaid sections
- Left out, never padded
- Structure reviewed
In order
Presenting Complaint · History of Present Illness · Past Medical History · Family & Social History · Review of Systems · Physical Examination · Assessment · Plan
What the Pediatrics: General Consult Note contains
8 sections8 sections, in the order the note puts them, and what each one takes from the visit.
- 1
Presenting Complaint
- Chief complaint in the caregiver words
- How long it has been going on
- 2
History of Present Illness
- Onset, symptom character, and severity
- Associated symptoms, fever, rash
- Feeding and activity level
- Sick contacts
- Treatment already tried
- 3
Past Medical History
- Relevant diagnoses and prior hospitalizations
- Birth history where relevant
- Medications and allergies
- Immunization status
- 4
Family & Social History
- Relevant family history
- Social context
- 5
Review of Systems
- Only the systems the caregiver raised
- 6
Physical Examination
- Vital signs including temperature and weight
- Focused examination findings
- 7
Assessment
- Working diagnosis or differential, as stated
- 8
Plan
- Medications prescribed
- Investigations ordered
- Advice given
- Safety-netting and return precautions
- Follow-up
Nothing padded
A section nobody said anything about is left out of the draft rather than padded. You will not find "not discussed" filling a heading you never covered.
This page describes how a note is structured. It is not clinical guidance, and the clinician who signs the note remains responsible for the record.
Questions about the Pediatrics: General Consult Note
4 questions- What sections does the pediatric consult note contain?
- Eight: Presenting Complaint, History of Present Illness, Past Medical History, Family and Social History, Review of Systems, Physical Examination, Assessment and Plan.
- Does the note keep what the caregiver said?
- Yes. The presenting complaint is taken in the caregiver words, and the history of present illness covers onset, symptom character and severity, associated symptoms such as fever and rash, feeding and activity level, sick contacts, and any treatment already tried.
- Is safety netting part of the plan?
- It is one of the things the plan records, alongside medications prescribed, investigations ordered, advice given and follow-up. Return precautions appear where the clinician gave them and are left out where nobody raised them.
- Who reviews the draft?
- You do, before anything is signed. The draft comes back from the visit for you to edit, and it stays outside the record until you sign it.
Other pediatrics formats
2 formatsThis format is one of the three built-in pediatric formats. See the AI scribe for pediatric clinics.
What holds true for your patient data
These apply from your first free session, on every plan, whichever format you write in. The technical detail is on the security and HIPAA page.
A BAA first
We sign a Business Associate Agreement with your clinic before any patient data is processed.
US servers only
Patient data is stored and processed only on servers in the United States.
Encrypted throughout
Recordings, transcripts and notes are encrypted in transit and at rest.
Never used for training
Patient conversations are never used to train AI models.
Yours to sign
Every note is a draft until the clinician reviews it and signs it.
See the Pediatrics: General Consult Note on one of your own visits
Bring a consultation. We will record it, show you the draft in this format, and tell you plainly if Notermed is not a fit yet.