SITUATION

PATIENT NAME:

[PEDIATRIC PATIENT'S NAME]

AGE:

[PATIENT'S AGE]

ROOM NUMBER:

[ROOM NUMBER]

PRIMARY NURSE:

[PRIMARY NURSE'S NAME]

PHYSICIAN:

[PHYSICIAN'S NAME]

DATE/TIME OF CHANGE:

[DATE AND TIME OF CHANGE]

BRIEF SUMMARY:

[BRIEF SUMMARY OF THE CHANGE IN THE PATIENT'S CONDITION]

CURRENT VITAL SIGNS:

[LIST OF CURRENT VITAL SIGNS]

SYMPTOMS:

[LIST OF SYMPTOMS OBSERVED]

MEDICAL HISTORY:

[BRIEF OVERVIEW OF THE PEDIATRIC PATIENT'S MEDICAL HISTORY]

ALLERGIES:

[LIST ANY KNOWN ALLERGIES]

CURRENT MEDICATIONS:

[LIST OF CURRENT MEDICATIONS AND DOSAGES]

RECENT PROCEDURES:

[LIST ANY RECENT MEDICAL PROCEDURES]

FAMILY INFORMATION:

[BRIEF OVERVIEW OF FAMILY HISTORY AND INVOLVEMENT]

PRIMARY ASSESSMENT:

[ASSESSMENT FINDINGS RELATED TO THE CHANGE IN CONDITION]

SECONDARY ASSESSMENT:

[ADDITIONAL ASSESSMENT FINDINGS]

CURRENT FLUID INTAKE/OUTPUT:

[FLUID INTAKE/OUTPUT MONITORING]

CURRENT PAIN LEVEL:

[PATIENT'S CURRENT PAIN LEVEL, IF APPLICABLE]

BEHAVIORAL OBSERVATIONS:

[OBSERVATIONS OF THE PATIENT'S BEHAVIOR]

IMMEDIATE ACTIONS:

[RECOMMENDATIONS FOR IMMEDIATE ACTIONS OR INTERVENTIONS]

MEDICATION CHANGES:

[PROPOSED CHANGES TO MEDICATIONS OR DOSAGES]

FURTHER MONITORING:

[INSTRUCTIONS FOR FURTHER MONITORING OF THE PATIENT]

CONSULTATIONS NEEDED:

[ANY SPECIALISTS OR CONSULTATIONS NEEDED]

FOLLOW-UP PLAN:

[PLAN FOR FOLLOW-UP CARE OR ADDITIONAL ASSESSMENTS]