Pediatric consult note template with examples

How to write a pediatric consult note, step by step

1. Open with the referral question and who provided the history: parent, caregiver, the child, or all three, and note the child's age and sex as the referrer framed it.
2. Take the HPI in developmental context. The same cough means different things at 4 months and 14 years; milestones, school, and daycare belong beside the symptoms.
3. Record birth and neonatal history once, properly: gestation, delivery, birth weight, NICU course, and newborn screening where relevant.
4. Document development as milestones achieved and any regression. 'Developing normally' without a single milestone is an assertion, not a history.
5. Confirm immunization status against the provincial schedule, and say whether you reviewed records or relied on caregiver report.
6. Plot growth and write the trend, not just today's percentiles. Crossing percentiles is a finding; a single point on a curve is a measurement.
7. Examine and record normal findings that matter to the differential, especially the negatives the referring clinician will look for.
8. Close with a plan the family can execute: investigations, therapies, medication with weight-based dosing, follow-up interval, and the specific symptoms that should trigger earlier contact.

Blank pediatric consult template

Reason for consultation:
Chief complaint (parent/child's words):
History of present illness:
Past medical history:
Birth and neonatal history (gestation, delivery, birth weight, NICU):
Developmental history (milestones, school/daycare, concerns):
Immunization history (up to date per provincial schedule? records seen?):
Medications:
Allergies:
Social history (caregivers, household, exposures):
Family history:
Review of systems:

Growth: weight / height / head circumference with percentiles, and trend:
Physical examination:
Diagnostic workup / laboratory results / imaging:

Differential diagnosis:
Diagnosis:
Treatment plan:
Medication management (weight-based doses in mg/kg where relevant):
Nutritional recommendations:
Developmental interventions / therapies:
Prognosis:
Follow-up plan:
Patient and parent education provided:
Recommendations to the referring clinician:
Referrals recommended:

Example: failure to thrive referral

Reason for consultation: Poor weight gain over 6 months.

HPI: Born at term, birth weight 3.4 kg. Tracked 50th percentile for weight until 8 months, now 3rd. Length steady at 25th, head circumference 40th. Eating three meals plus two snacks; parents report he "throws half of it." No vomiting, diarrhea, fevers, or urinary symptoms. Energy and play normal per parents and daycare.

Development: Walking independently at 13 months, five words, pincer grasp. No regression. Immunizations up to date per Alberta schedule; record reviewed.

Growth today: Weight 8.1 kg (3rd percentile), length 76 cm (25th), HC 47 cm (40th). Trend is the finding: isolated weight deceleration with preserved length and head growth.

Examination: Alert, interactive toddler. No dysmorphic features. Mouth, chest, abdomen, skin unremarkable. Muscle bulk mildly reduced.

Assessment: Most consistent with inadequate caloric intake relative to needs (meal structure, grazing, juice intake to clarify) rather than an organic wasting process, given preserved length/HC, normal development, and a well child. Celiac disease, thyroid disease, and occult infection remain on the differential if intake correction fails.

Plan: Three-day diet record reviewed with a pediatric dietitian (referral sent). Structured meals and snacks, no juice, calorie-dense additions discussed with parents in the visit. Baseline CBC, ferritin, TSH, celiac serology drawn today. Weight recheck in 4 weeks with me; if weight has not responded, GI referral and broader workup. Parents given written feeding plan and told to call sooner for vomiting, diarrhea, or lethargy.

Who uses a pediatric consult note, and when

Pediatricians, family physicians, and nurse practitioners write pediatric consult notes in general pediatrics, emergency, and subspecialty clinics — always with the caregiver's account and the child's developmental context in frame.

• New referrals for growth, development, or chronic symptoms.
• Emergency and urgent-care assessments sent back to primary care.
• Subspecialty reviews (allergy, respiratory, GI, neurology) coordinating shared care.
• School and developmental concern assessments feeding psychoeducational planning.
• Hospital discharge and follow-up summaries for complex children.

Documentation, privacy, and record-keeping in Canada

Pediatric notes document two voices: the historian (usually a parent or guardian) and the child. Name the historian and their relationship, record immunization status explicitly, and document consent and who accompanied the child. In Canada, mature-minor principles and provincial rules govern adolescent confidentiality — sensitive history taken alone with the teen should be recorded with the same care as the physical findings. Growth parameters plotted and interpreted, not just listed, are what regulators and receiving clinicians look for.

Across Canada, clinical notes form part of the legal medical record. Provincial regulators expect entries that are contemporaneous, factual, and attributable; health information is handled under provincial privacy law (such as PHIPA in Ontario, the HIA in Alberta, and Law 25 in Quebec) and PIPEDA where it applies. Disclose the minimum necessary, with patient consent, and record amendments as amendments — never by overwriting the original entry.

Common mistakes that weaken a pediatric consult note

• Recording weight and height with no percentiles or growth trajectory.
• Leaving immunization status as 'up to date' with no source or record review.
• Omitting developmental milestones in a note about a developmental concern.
• Writing the plan for the parent with no anticipatory guidance or return precautions.
• Missing birth history in infants where it changes the differential.
• No weight-based dose check documented for new prescriptions.

Sections that get skipped, and why they matter

• Birth history in a 14-year-old feels irrelevant until it isn't: prematurity explains a lot of school and growth referrals.
• Immunization status is a consult question in itself for internationally adopted children and families new to Canada; say whether you saw records or took a history.
• Growth is a trend, not a number. One percentile without the trajectory wastes the referral.
• Parent education belongs in the note: half of pediatric management is what happens at home between visits.
• Weight-based dosing: write mg/kg for anything you recommend starting, so the prescriber is not reverse-engineering your plan.

Pediatric consult vs adult consult: what changes

Example 2: recurrent wheeze, daycare-aged child

Reason for consultation: Recurrent wheeze, three episodes in 5 months, two ED visits treated as viral wheeze.

HPI: Each episode followed a cold by 2–3 days: cough, wheeze heard by parents, work of breathing that settled over 3–4 days. Between episodes he is well, runs and plays without cough. No eczema, no food allergy. Attends daycare full-time. Born at term, no NICU, immunizations up to date on records reviewed. Father had childhood asthma.

Growth: Weight and height tracking 50th–75th percentiles, no crossing. Development normal, speech in sentences.

Examination today (well): Alert, playful. Chest clear, no wheeze, no increased work of breathing. Ears, nose, throat unremarkable. No clubbing.

Assessment: Recurrent viral-triggered wheeze, preschool pattern. Asthma cannot be confirmed or excluded at this age; atopic background (paternal asthma) raises the probability this evolves into asthma. No features today suggesting an alternative cause such as foreign body (episodes are bilateral and illness-linked, not sudden and monophonic) or chronic suppurative disease.

Plan: Salbutamol with spacer for episodes, technique taught to both parents today and written down. Trial of a written wheeze action plan for the next two illnesses, with a symptom diary. No daily controller started today; if he needs salbutamol more than twice in the next episode, or has another ED visit, family doctor to start a 3-month inhaled corticosteroid trial and re-refer. Return precautions reviewed: increased work of breathing at rest, poor fluid intake, or cyanosis means same-day assessment. I will review after the next two illnesses or in 4 months, whichever comes first.

Frequently asked questions

References

1. Good practices in medical record keeping — Canadian Medical Protective Association (CMPA)
2. Medical Records Documentation — practice standard — College of Physicians and Surgeons of Ontario (CPSO)
3. Personal Health Information Protection Act (PHIPA) — Government of Ontario
4. Position statements and practice points — Canadian Paediatric Society
5. Canadian Immunization Guide — Public Health Agency of Canada

Examples on this page are fictional and for illustration only; they do not describe real patients. Templates reflect the corresponding built-in template in Scribeberry at the date above.