Take the history. Vero writes the H&P.
Vero Scribe writes the pediatric H&P in your template from your conversation with the family, with their consent, or from your dictation. You review and edit it, then copy it into your chart or EHR.
Pediatric H&P Template
A pediatric H&P is the full history and physical for a child who is being admitted or is new to you. Copy the free template, see an admission and a new-patient example, and check what each part needs.
- Free, no account needed
- Word and text downloads
- Two filled examples
Blank pediatric H&P template
FreePEDIATRIC HISTORY AND PHYSICAL Patient: [Name] Date of birth and age: [Date; age in years and months] Date and time: [Date, time] Encounter: [Admission, transfer, or new patient visit] Source of history: [Parent, caregiver, child, or records; interpreter if used] Legal guardian: [Name and relationship] Referred by: [Clinician or service, if any] Clinician: [Name, credentials] HISTORY OF PRESENT ILLNESS Chief complaint: [Reason for admission or visit, in the caregiver's or child's words] History: [Onset, course, symptoms, intake and output, treatments tried, sick contacts] Emergency or clinic course: [Findings, treatments given, and the response before admission] PAST HISTORY Prenatal and birth: [Pregnancy problems, gestational age, birth weight, delivery, neonatal or NICU stay] Medical: [Chronic conditions, previous admissions, emergency visits] Surgical: [Procedures, anesthesia problems] Immunizations: [Up to date per local schedule, or doses missing; source of the record] Medications: [Name, dose in mg and mg/kg, frequency] Allergies: [Drug, food, and other allergies, with reactions] DEVELOPMENT AND NUTRITION Development: [Milestones by domain, delays, therapies] School or childcare: [Grade or setting, progress, attendance] Feeding and diet: [Breast milk or formula with volumes for infants; diet, restrictions, and appetite for older children] Growth history: [Weight gain, previous percentiles] FAMILY AND SOCIAL HISTORY Family history: [Conditions in parents and siblings, such as asthma, allergy, early heart disease, sudden death, inherited conditions] Home: [Who the child lives with, siblings, other caregivers] Exposures: [Smoke or vaping, pets, travel, sick contacts] Supports and safety: [Services involved, financial or food needs, safety concerns] Adolescent history: [Confidential psychosocial history, such as HEEADSSS, with time alone] REVIEW OF SYSTEMS Review of systems: [Pertinent positives and negatives by system] PHYSICAL EXAMINATION Growth: [Weight, length or height, and head circumference under age 2, with percentiles] Vital signs: [Temperature, HR, RR, BP, SpO2 with oxygen and flow, against age-based ranges] General: [Appearance, interaction, distress] Systems: [Findings by system, adapted to age] RESULTS Results: [Labs, imaging, and other tests, with times] ASSESSMENT AND PLAN Summary: [Age, sex, key history, and main findings in one or two sentences] Problem 1: [Problem, severity, and plan, with mg/kg and calculated doses] Problem 2: [Problem and plan] Fluids and nutrition: [Feeds or IV fluids, route, and rate] Monitoring: [Vital signs, oxygen saturation, intake and output, escalation criteria] Family: [What was discussed with the caregivers, and their questions] Disposition: [Unit and level of care, or follow-up; discharge criteria] Signed: [Clinician name, credentials, date and time]
Use it for
- Pediatric admissions
- New patient visits
- Transfers of care
- Pre-procedure workups
- Emergency department
Two filled examples. Every part, filled in.
Each one follows the template. Use them to judge how much detail every part needs.
Pediatric H&P: bronchiolitis admission
Pediatric ward, admission from the emergency department
History of present illness
Chief complaint, per his mother: “breathing fast and not finishing his bottles.” 6-month-old boy with a runny nose and cough for 4 days. Over the last 24 hours, faster, harder breathing and poor feeding: about 450 mL (15 oz) of formula instead of his usual 900 mL (30 oz), and 3 wet diapers instead of 6. Highest temperature 38.3 °C (100.9 °F). One vomit after coughing. No pauses in breathing, color change, diarrhea, or rash. His 3-year-old sister has a cold. Emergency course: SpO2 87 to 89% on room air when settled; nasal suction; oxygen 1 L/min by nasal cannula started, SpO2 now 94 to 96%. Observed feed: took 40 mL, then tired. RSV test positive. No bronchodilator or chest x-ray, in line with the bronchiolitis pathway.
Past history
Born at 39 weeks by vaginal delivery, birth weight 3.3 kg (7 lb 4 oz), no NICU stay. No previous wheeze, admissions, or surgery. Immunizations up to date per local schedule, from his immunization record; 6-month vaccines due. No RSV antibody or maternal RSV vaccine recorded. No regular medicines; acetaminophen at home, last dose 6 hours ago. No known drug allergies.
Development and nutrition
Rolls both ways, sits with support, reaches for toys and passes them between hands, babbles, and laughs. Formula 180 mL (6 oz) 5 times a day; started purées 2 weeks ago. Growing along his curve at previous visits.
Family and social history
Mother had asthma as a child; no heart disease or immune problems in the family. Lives with both parents, who are his legal guardians, and his sister, who attends daycare. Father smokes, outside the home only.
Review of systems
Positive: cough, runny nose, fast breathing, poor feeding, fewer wet diapers, low-grade fever. Negative: pauses in breathing, color change, diarrhea, rash, unusual sleepiness.
Physical examination
Weight 7.6 kg (16.8 lb), 35th percentile; length 67 cm (26.4 in), 40th; head circumference 43.5 cm (17.1 in), 50th. T 38.1 °C (100.6 °F), HR 158, RR 62, SpO2 95% on 1 L/min nasal cannula. Alert and consolable, moderate work of breathing. Copious clear nasal secretions. Subcostal and intercostal retractions, no grunting. Fine crackles and wheeze throughout both lungs. Heart regular, no murmur; capillary refill under 2 seconds. Anterior fontanelle soft and flat; mucous membranes slightly dry; tears present. Abdomen soft. Good tone. No rash.
Results
RSV positive. No blood tests or chest x-ray needed for typical bronchiolitis.
Assessment and plan
Previously healthy 6-month-old, born at term, with RSV bronchiolitis on day 4 of illness: low-flow oxygen need, moderate work of breathing, and mild dehydration from poor feeding. Days 3 to 5 are often the worst. 1. Bronchiolitis: supportive care, with nasal suction before feeds. Oxygen by nasal cannula if SpO2 stays below 90%, per the unit’s bronchiolitis pathway; wean as tolerated. No bronchodilators, steroids, or antibiotics. Escalate per institutional protocol for a rising oxygen need, worsening work of breathing, pauses in breathing, or tiring. 2. Hydration: small, frequent feeds; strict intake and output; daily weight. If intake stays under half of usual, NG feeds or isotonic IV fluid with dextrose per protocol, maintenance about 30 mL/h for 7.6 kg. 3. Fever and comfort: acetaminophen 15 mg/kg = 114 mg, 3.6 mL of 160 mg/5 mL, every 6 hours as needed. Contact and droplet precautions per hospital policy. Expected course and smoke exposure discussed with his mother; quit-smoking support offered to his father. Admit to the pediatric ward. Discharge when off oxygen, feeding enough to stay hydrated, and the family feels confident.
Pediatric H&P: new patient with asthma
Pediatric clinic, new patient visit
History of present illness
Chief complaint, in her words: “my asthma stops me in gym.” 10-year-old girl, new to the practice after a move, with her mother; history from both. Asthma diagnosed at age 5. Over the last 4 weeks: daytime cough or wheeze 3 to 4 days a week, night waking twice, reliever 3 times a week, and stopping early in gym class. Triggers: colds, exercise, cold air, and a friend’s cat. One emergency visit and one course of oral steroids in the past year; never admitted. Low-dose inhaled corticosteroid prescribed twice daily but taken only during colds; inhaler used without a spacer. Childhood Asthma Control Test: 17, below the cutoff for good control.
Past history
Born at term, no NICU stay. Eczema as a baby, now mild. Seasonal allergic rhinitis. No surgeries. Immunizations up to date per local schedule, from the record her mother brought; influenza vaccine not yet this season. Medications: albuterol (salbutamol) inhaler, 2 puffs as needed; low-dose inhaled corticosteroid, prescribed but rarely taken. No known drug allergies; itchy eyes and wheeze around cats.
Development and nutrition
Met milestones on time. In grade 5, doing well; missed 3 school days this term with asthma. Plays soccer. Eats a varied diet; no restrictions.
Family and social history
Father has asthma; mother has hay fever. Lives with her mother, who is her legal guardian, and a 7-year-old brother. No smokers at home, no pets. Her school has no asthma action plan on file.
Review of systems
Positive: exercise-related cough and wheeze, night cough, sneezing and itchy eyes in spring. Negative: chronic wet cough, weight loss, snoring, heartburn, noisy breathing on breathing in.
Physical examination
Weight 34 kg (75 lb), 60th percentile; height 140 cm (55.1 in), 55th percentile; BMI 17.3, 60th percentile. T 36.7 °C (98.1 °F), HR 84, RR 18, BP 102/64, SpO2 99% on room air. Well, no distress, speaking in full sentences. Pale, swollen nasal turbinates. Chest clear with good air entry, no wheeze, no chest deformity. No clubbing. Dry skin in the elbow creases.
Results
Spirometry today: FEV1 82% predicted, FEV1/FVC 0.78; FEV1 up 14% after bronchodilator, consistent with reversible airflow obstruction. Previous records requested.
Assessment and plan
10-year-old girl with asthma that is not well controlled, mainly from missed controller doses and poor inhaler technique, with untreated allergic rhinitis. 1. Asthma: restart a daily low-dose inhaled corticosteroid twice a day with a spacer; reliever as needed. Technique taught and checked by teach-back. Written asthma action plan given, with a copy and a spare reliever for school. Influenza vaccine given today. 2. Allergic rhinitis: fluticasone nasal spray, 1 spray in each nostril once daily; limit time around cats. 3. Eczema: daily moisturizer. Seek urgent care if the reliever is needed more often than every 4 hours or isn’t helping; call 911 for trouble speaking or walking, or blue lips. Follow-up in 4 to 6 weeks to review control and technique before any step-up.
What goes in each part.
History of present illness
The story of this illness from the caregiver, and from the child when old enough, through to the decision to admit or the plan.
- The chief complaint in the family’s words
- Who gave the history, and an interpreter if one was used
- Intake and output against usual, with wet diapers or voids
- Treatments already given, and the emergency or clinic course
Avoid: Leaving out the source. A history from a parent at the bedside reads differently from one pieced together from records.
Past history
Everything before this illness, starting from pregnancy and birth.
- Gestational age, birth weight, and any NICU stay
- Chronic conditions, admissions, and surgeries
- Immunizations against the local schedule, and the source
- Medications in mg and mg/kg, and allergies with reactions
Avoid: Skipping the birth history in an older child. Prematurity or a NICU stay still matters for breathing, growth, and development.
Development and nutrition
Where the child is developmentally and how they eat, which shapes both the exam and the plan.
- Milestones by domain, or school grade and progress
- Delays, therapies, or extra support at school
- Feeds and volumes for infants; diet and restrictions for older children
- Growth history and previous percentiles
Avoid: Writing “development normal” for a child you can’t yet assess. Record the milestones the caregiver describes and what you see.
Family and social history
Who looks after the child, where they live and learn, and the risks and supports around them.
- Family conditions, such as asthma, early heart disease, or sudden death
- Caregivers, and the legal guardian
- Smoke and vaping exposure, pets, and travel
- For adolescents, a confidential psychosocial history
Avoid: Not naming the legal guardian. Consent for treatment depends on it.
Physical examination
Growth and vital signs first, read against age, then the exam by system.
- Weight, length or height, and head circumference under age 2, with percentiles
- Vital signs against age-based ranges, with oxygen and flow
- Work of breathing and hydration in an acutely ill child
- An exam adapted to the child’s age and cooperation
Avoid: Leaving out the weight. Every dose and fluid rate in the admission depends on it.
Assessment and plan
A summary line, then a plan for each problem, written so every shift works toward the same goal.
- Severity of each problem, with the supporting findings
- Doses as mg/kg with the calculated dose
- Fluids and feeds, with the rate
- Monitoring and escalation criteria
- Discharge criteria, and what was discussed with the family
Avoid: Admitting without discharge criteria. Say what “ready to go home” means for this child.
Common mistakes, and how to avoid them.
Copying the emergency department history
Take the history again with the family. Details change, and the timeline matters for illnesses like bronchiolitis that peak around days 3 to 5.
Doses without the weight used
Write the weight and the date it was measured with the medication plan, and show mg/kg for every dose so pharmacy and nursing can check it.
Immunizations with no source
Say where the status came from: the record, a registry, or the parent’s report. “Up to date” from memory may not be.
No confidential history for adolescents
Take part of an adolescent’s history without the parent present, and note that you did. Follow your local rules on consent and on what can be shared.
Vague escalation criteria
Write what should prompt a call, such as an oxygen need above a set flow, a rising breathing rate, pauses in breathing, or poor intake. Night staff act on clear thresholds.
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Frequently asked questions.
What is included in a pediatric H&P?
Everything in an adult H&P, plus the prenatal and birth history, development, immunizations, feeding and diet, growth with percentiles, and the child’s caregivers, home, and school. Doses are written per kilogram.
How is a pediatric H&P different from an adult H&P?
The history often comes from a caregiver, and it adds birth, developmental, immunization, and feeding history. Growth is plotted on percentile charts, vital signs are read against age, and medication doses are calculated by weight.
How do you document an adolescent’s confidential history?
Note that part of the history was taken without the parent present, and the framework you used, such as HEEADSSS. Record it in a way that respects your local consent and confidentiality rules.
Can I use the same template for an admission and a new patient?
Yes. For an admission, fill in the emergency course, monitoring, and discharge criteria. For a new patient visit, those lines become the follow-up plan and the records to request.
Is this pediatric H&P template free?
Yes. Copy it, or download it as a Word or text file. No account needed.
More pediatrics templates, and guides.
Pediatric SOAP note template
The sick-visit SOAP note for children, with caregiver history, hydration, and weight-based doses.
Well-child visit template
Growth, development, screening, vaccines, and safety guidance, with 12-month and 5-year examples.
Newborn exam template
Birth history, feeding and weight change, the full newborn exam, jaundice, and newborn screens.
HEEADSSS assessment template
The adolescent psychosocial interview, from confidentiality and home life to safety online.
AI history and physical notes
How Vero drafts H&P notes from the visit for you to review.
Review of systems
ROS examples, and a free blank ROS template.
Vero for pediatrics
Notes, family instructions, and follow-up for pediatric practices.
Common ICD-10 codes
The codes used most often in pediatrics.
Your template. Filled in from the visit.
Vero writes your notes and letters in the templates you choose, so you review instead of type.
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