What should be included in a pediatrics case sheet proforma at a hospital?

Pediatric Case Sheet Proforma Components

A comprehensive pediatric case sheet must include patient demographics, detailed health history with specific focus on perinatal and developmental milestones, complete vital signs, focused physical examination including growth parameters, and a systematic review of systems with particular attention to cardiac, pulmonary, and neurological function. 1, 2

Patient Demographics and Identification

• Name, address, telephone number of child and parent/caregiver's cell phone 1, 2
• Age and weight in kilograms, with gestational age at birth for infants (preterm infants may have sequelae such as apnea of prematurity) 1, 2
• Name and contact information of the child's personal care provider or medical home 1, 2
• Date of birth and medical record number 2

Vital Signs (Document at Every Visit)

• Heart rate, blood pressure, respiratory rate 1, 2
• Room air oxygen saturation 1, 2
• Temperature (use mercury-free thermometers with Celsius measurements) 1, 2
• Height, weight, and BMI with automatic plotting on age- and sex-appropriate growth charts 1
• Head circumference for infants and young children 1
• Document if vital signs cannot be obtained due to patient non-cooperation 1, 2

Comprehensive Health History

Allergies and Medications

• Food and medication allergies, including previous allergic or adverse drug reactions 1, 2
• Complete medication history: prescription, over-the-counter, herbal supplements, and illicit drugs with dosage, time, route, and site of administration 1, 2
• Herbal medicines (St John's wort, ginkgo, ginseng, garlic, kava, valerian) that may interfere with drug metabolism 1

Perinatal and Birth History

• Gestational age at birth 1, 2
• Pre- and perinatal complications 1
• Newborn screening results (for inborn errors of metabolism, congenital heart disease) 1
• Apgar scores 1

Past Medical History

• Relevant diseases and physical abnormalities: genetic syndromes, neurologic impairments, obesity, cervical spine instability (Down syndrome, Marfan syndrome, skeletal dysplasia) 1, 2
• History of snoring or obstructive sleep apnea (children with severe OSA require lower opioid doses) 1, 2
• Seizure disorder history 1, 2
• Previous hospitalizations with summary of relevant admissions 1, 2
• History of sedation or general anesthesia and any complications or unexpected responses 1
• Growth patterns and whether normal 1
• Developmental milestones across categories with assessment of any concerns about development or behavior 1
• Previous illnesses, injuries, emergencies, and surgeries 1

Family History

• Sudden unexplained death in first- or second-degree family members before age 35, particularly as an infant 1
• Long QT syndrome, arrhythmias 1
• History of autoimmune disease 1
• Relevant genetic conditions (muscular dystrophy, malignant hyperthermia, pseudocholinesterase deficiency) 1

Social and Environmental History

• Family structure and individuals living in home 1
• Housing conditions: general, water damage, mold problems 1
• Exposure to tobacco smoke, toxic substances, drugs 1
• Recent changes, stressors, or family strife 1
• Support systems and access to needed resources 1
• Previous child protective services or law enforcement involvement (domestic violence, alerts for this child or siblings) 1
• Exposure of child to adults with mental illness or substance abuse 1
• School/work schedules and ability to engage in care 1

Recent History and Interval Changes

• Illness in preceding days: fussiness, decreased activity, fever, congestion, rhinorrhea, cough, vomiting, diarrhea, decreased intake, poor sleep 1
• Injuries, falls, previous unexplained bruising 1
• Recent exposure to infectious illness, particularly upper respiratory illness, paroxysmal cough, pertussis 1
• Vaccination history and needs 1
• Last dental visit 1

Pregnancy Status

• Document pregnancy status for menarchal females (as many as 1% presenting for procedures are pregnant) due to concerns for adverse effects of medications on the fetus 1, 2

Review of Systems

Focus specifically on abnormalities of cardiac, pulmonary, renal, or hepatic function that might alter expected responses to medications 1, 2

• Specific query regarding sleep-disordered breathing and obstructive sleep apnea 1, 2
• Respiratory symptoms: breathing difficulties, noisy breathing, snoring 1
• Gastrointestinal: reflux (obtain details including management), feeding patterns 1
• Neurological: developmental concerns, behavioral issues 1
• Screening for depression, anxiety, diabetes distress, disordered eating 1

Physical Examination

General Examination

• Growth and pubertal development in children and adolescents 1
• Orthostatic blood pressure when indicated 1
• Skin examination: acanthosis nigricans, insulin injection sites, lipodystrophy 1
• Thyroid palpation 1

Focused Airway Assessment

• Tonsillar hypertrophy 1, 2
• Abnormal anatomy (mandibular hypoplasia) 1, 2
• Mallampati score (ability to visualize hard palate or uvula) to determine increased risk of airway obstruction 1, 2

Physical Status Evaluation

• ASA classification for procedural cases 1, 2

Assessment and Management Plan

• Document positive findings noted during evaluation 2
• Formulate specific management plan 2
• For hospitalized patients, document that chart was reviewed 1, 2

Special Documentation for Procedures

• Time-based record including name, route, site, time, dosage/kilogram, and patient effect of administered drugs 1
• "Time out" confirmation of patient's name, procedure to be performed, and site/laterality 1, 2
• Monitoring data: level of consciousness, responsiveness, heart rate, blood pressure, respiratory rate, oxygen saturation until predetermined discharge criteria met 1, 2

Common Pitfalls to Avoid

• Failing to document when vital signs cannot be obtained due to patient non-cooperation 1, 2
• Omitting medication history that could interact with treatments, particularly herbal supplements 1, 2
• Inadequate documentation of allergies and previous adverse reactions 1, 2
• Not calculating medication dosages per kilogram of body weight (for obese patients, adjust to ideal body weight rather than actual weight) 1
• Missing developmental milestone assessment across multiple categories 1
• Overlooking family history patterns of sudden death or genetic conditions 1