Clinical Reference Systems: Pediatric Advisor 10.0

1. Patient's Name ____________________________________

2. Diagnosis: Your child's diagnosis is ____________________________

3. Discharge Instructions
   • For pain or fever over 102ƒF (39ƒC) give ____________________________

     ____ mg of acetaminophen every 4 to 6 hours OR

     ____ mg of ibuprofen every 6 to 8 hours

   • ______________________________________________________________
   • ______________________________________________________________

4. Additional Instructions
   • _______________________________________________________
   • _______________________________________________________
   • _______________________________________________________

5. Follow-up Appointment after Discharge

   ___ Your child needs to be rechecked and has an appointment on _____________ at _______ with _________________________.

   ___ Your child needs to be rechecked in ________ days. Call your child's doctor to make an appointment.

   ___ A follow-up appointment is not necessary. Call your doctor if you have any concerns.

6. Call your doctor if any of the following occur (phone number: ___________):
   • _______________________________________________________
   • _______________________________________________________
   • _______________________________________________________

7. Caregiver's name __________________________ Date___________