How do you correctly word a pediatric assessment?

[Bodie43]

I'm having trouble figuring out the correct words to use to document the general appearance section of my first pediatric physical assessment. Are there any examples to look at because I keep getting hung up on the words and how much to go into in the general appearance section. I think I will be OK on the different sections such as skin, nose and chest because I know what I'm looking for. I may be making this harder than it is but I just saw where someone wrote "Development is impressive" and I have no real idea what that means or if it's just in there to sound fancy. I looked up development in my PEDS book and I don't see any description that uses impressive. If anyone knows where I could find some examples I'd really appreciate it. I looked on this site but all the ones are old and not working when you click on them. Thanks

[tarheelsu]

I would word the physical assessment pretty much you would for an adult patient . . . results of your head to toe, etc. Then I would look up what developmental tasks they should have accomplished according to their age and document that. Ex -- developmental milestones appropriate for age. I don't think "development is impressive" is good, first of all its too vague. I think what you are looking for is if their height and weight are appropriate for age, their fine/gross motor, speech, social development etc.

[Bodie43]

Thanks for the help

[xtxrn, ASN, RN]

"Development is impressive" tells me absolutely nothing. Impressive to who and in what way? It's vague and nutty.

Just go by basic assessment: baby looks at nurse upon entering room, and smiles; tracks with eyes in all directions. (then physical exam- lungs clear, HRR, etc) Baby is calm and comfortable in mom's arms. Taking bottle feeds well w/ 180cc q4h. #3 wet diapers this shift w/o odors.

[Jennifer0512]

I don't like the wording of "development is impressive". It should definitely be more specific-make sure to touch on specific gross motor, fine motor, personal/social, and language development for pediatric development and whether those are normal for the baby or child's age.