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Paediatrics

Child health documentation with age-appropriate frameworks and safeguarding considerations.

Documentation Overview

Paediatric documentation requires age-appropriate normal values, developmental context and a lower threshold for escalation. Safeguarding considerations must be integral to all paediatric documentation.

Key Documentation Standards

  • Age and weight documented on all entries — weight-based calculations required
  • Developmental stage considered in assessment
  • Parental/guardian consent documented
  • Safeguarding concern documented using local pathway
  • Age-appropriate normal ranges used for vital signs and observations
  • Paediatric Early Warning Score (PEWS) recorded

Common Documentation Scenarios

  • Febrile child — age, temperature, source, NICE traffic light documentation
  • Breathing difficulty — work of breathing, SpO2, response to treatment
  • Safeguarding concern — objective description, actions taken, referral made
  • Neonatal admission — birth history, feeding, weight, screening status
  • Developmental concern — milestone documentation, referral pathway
  • Child with disability — capacity considerations, communication adaptations

Relevant Templates

Quick Reference
PAEDIATRIC DOCUMENTATION CHECKLIST
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BASIC INFO (every entry)
□ Date of birth AND age
□ Weight (kg)
□ Responsible adult / guardian

VITAL SIGNS (age-appropriate ranges)
Age       HR        RR        BP
<1yr      110-160   30-60     70-90
1-5yr     90-140    25-40     80-100
5-12yr    70-120    20-30     90-110
>12yr     60-100    15-20     100-120

□ PEWS calculated and documented

HISTORY
□ From parent AND child (age appropriate)
□ Birth history if relevant
□ Immunisation status
□ Developmental milestones

SAFEGUARDING
□ Injury consistent with history?
□ Appropriate supervision?
□ Previous presentations reviewed
□ Concerns documented and actioned

DISCHARGE
□ Parent/carer understands plan
□ Written safety-netting provided
□ Follow-up arranged
□ GP informed
Specialty-specific: Always refer to your hospital's specialty-specific documentation policies and national guidelines.