presentation on file system suggested protocol in pediatric hospital. it was during my internship 2013

3. Progress paper
• Progress Notes are the part of a medical
record where healthcare professionals record details to
document a patient's clinical status or achievements during the
course of a hospitalization or over the course of outpatient
care. Reassessment data may be recorded in the Progress Notes
• Symptom fallow up paper has rule in monitoring the clinical
status on many levels in order to deliver best medical care
possible for ill chidren and to achieve less hospitalization and
more care in same time.
• Progress notes are written by both physicians andnurses to
document patient care on a regular interval during a patient's
hospitalization
• Progress paper is divided into 3main aspect of fallow up.
• 1- history and examination
• 2- impression and DD
• 3- plan

4. •PROGRESS NOTES
•Progress notes should be concise and convey information
about the patient’s status, test results, and current
treatments and plans.
•Editorial comments, criticisms of other services or other
health care professionals, and humor should be avoided.
•Most hospitals use some modification of the SOAP note as
the standard for progress notes: subjective (what the
patient says he or she feels), objective (what the physical
examination reveals), assessment (interpretation of the
information obtained), plan (treatment plan).

5. •S: What happened overnight – per mom, per nurse, per pt. Eating
•(tolerating PO? Any emesis?), peeing, pooping.
•O: Vitals: T max for last 24h – note other fever spikes (when)
•Tcurrent –
•HR + 24h range –
•RR + 24h range –
•BP + SBP range/DBP range over 24 h –
•O2 sat + 24h range –
•Daily weight –
•I/Os – 24h total in (broken down by IV/PO) over 24h total
•out = total up or down in cc/kg in younger kids or Kcal/kg for
•babies on formula
•UOP – Record as cc/kg/hr (>1 is nml) and stool output (<20
•is nml).
•PE: At least GEN, HEENT, RESP, CV, ABD, EXT, NEURO
•Labs/Studies –
•A/P: Briefly state overall impression. Then work up differential
•diagnosis. Break down plan by system. You may see ‘PO ad lib’ in
•the FEN section.

6. •STRUCTURE OF PROGRESS NOTE:
•A. Subjective (S): Information provided by the, patient, their family or custodian concerning
events of the previous 24 hours, e.g. any
•problems overnight, improvement/deterioration in patients condition. If the patient is
unattended by family and is either too
•young or ill to communicate, make a notation about this setting and otherwise leave this
section, blank. Please
•B. Objective (0):
•1. Vital signs including maximum temperature. recorded over the previous 24 hours
•2. Weight: intake and output over the past 24 hours. (These should always be recorded
inpatients with conditions where there are
•caloric intake problems or actual/potential fluid derangements e.g. failure to thrive,
gastroenteritis,
•meningitis, etc.
•3. General Appearance. This arguably can be the most important detail listed under the
objective criteria. Describe the patient's
•appearance as you find he/she on your entrance to the room noting sate of consciousness,
orientation,
•activity level, etc.
•4. Physical findings by organ system as pertinent to the patients underlying problem(s)..

7. •5. Laboratory Tests:
•a. blood tests b. urine
•c. other body fluids
•d. cultures (ideally list date and site from which obtained)
•e. miscellaneous tests
•f. radiographic tests
•C. Assessment
•(A): list in order patients’ problems/diagnoses including
differentials, beginning with problem(s) for which patient
•was admitted followed by new disorders. Be sure to update
assessments on a daily basis.
•D. Plans (P): list your plans for each diagnosis. Be as specific as
possibleyour notes

9. Name of doctor -----------------
Signature --------------------
Name of patient:------------
Age of child:-------------
Date
time
History: event in last
24hr
pulse-----B/MIN RR-----C/MIN temp ----C BP----mmHG
HC----cm( ) Lngth/ HT----cm ( ) WT-----kg ( )
Examinations vitals
Measurment
General
respiratory
Cadiovascular
Neurological
Abdominal
Others ( genetalia – joints)
Other systemic examination
a. blood tests
b. urine
c. other body fluids
d. cultures (ideally list date and site from which obtained)
e. miscellaneous tests
f. radiographic tests
. Laboratory Tests:
List the child problem and management for each
problem
Assement plane

10. •.
•The PROBLEM ORIENTED NOTE:
•To be seen
•Night round
•For more chronic, difficult or involved patients you may prefer to use the problem-oriented note. It may be
•less confusing and easier to organize.
•DATE/ TIME
•1) diagnosis/ problem( )
•2) Vitals pulse BP temp RR
•3) General conditon ---------------------------------------------------
•------------------------------------------------------------------------------
•4) System involved ----------------------------------------------------
•--------------------------------------------------------------------------------
•5) Last investigations results -----------------------------------------
•--------------------------------------------------------------------------------
•--------------------------------------------------------------------------------
•--------------------------------------------------------------------------------
•Plan according to problem investigation results --------------------------------------------------------
•-----------------------------------------------------------------------------------------------------------------------
•------------------------------------------------------------------------------------------------------------------------
•-------------------------------------------------------------------------------------------------------------------------
•note: NURSES' NOTES ARE NOT SUBJECTIVE, BUT RATHER OBJECTIVE OBSERVATIONS AND ARE
•NOT TO BE INCLUDED IN THIS SECTION

11. Example of nurse progress note
•Nursing Progress Note at 1440--------------------------------------------------------------------
S/O: Vital signs stable. Chest has good air entry bilaterally to bases with occasional
wheezes to LUL and RUL. Oxygen saturation 95 - 96 % on room air. No wheezes
present post Ventolin inhalation treatment. Progressed from Ventolin masks q2h
to q4h today. Patient is eating and drinking well. Intake= 500cc, Output= 485cc.
Skin is warm and dry. Capillary refill is < 2 seconds in all extremities. Mom
expressed concern about return of symptoms after discharge. Teaching done re:
symptoms to watch for, when to seek out medical care, and when to come back to
emergency department. Also gave number for Telehealth Ontario.----------------------
-------------------------------------------------------------------
A : Pt stable at present. Respiratory status improved over the course of the shift ---
--------------------------
P : Reinforce discharge teaching and ensure patient/family has no further
concerns. Continue to monitor effect of Ventolin inhalation treatment. Continue
with plan of care (Signature, 4th year Nursing Student, University of Windsor).
Co-signed by: Signature, RN.