There are usually several types of clinical documents that can be issued by a hospital center:

History report.

It is the report that collects the information obtained in the first visit. The first neuropediatric visit lasts 30 minutes and consists of several parts:

  • Medical record.
  • Current illness. It consists of the description of the reason for consultation and the systematic assessment of the symptoms that motivated the assessment, in the child's current context (familiar, school and of neurodevelopment), as well as information on other biological aspects that may be relevant, such as dream or food.
  • Clinical examination.
  • Complementary tests. They are all those examinations (radiological, analytical, genetic, psychological) that support the diagnostic process.
  • Diagnosis. Usually, during the first visit, a suspected diagnosis (ID: diagnostic impression) is proposed, or a differential diagnosis is proposed, which will have to be specified in subsequent visits.
  • Plan. A therapeutic diagnostic plan is established.
Progress note report.

It is the report that collects the information from the follow-up visit, which usually consists of a 15-minute interview in which several aspects are explored:

  • Current problems. All those clinical circumstances on which active work is being carried out during the visit.
  • Complementary tests. This section refers to the results of pending tests and collects relevant data for the current problem.
  • Diagnosis. The diagnosis can be updated in successive visits based on the information obtained in complementary tests, the response to treatment, or new symptoms reported by the family.
  • Plan. A diagnostic-therapeutic plan is established
Discharge report.

This is an "epicrisis", a summary with all the relevant information from the clinical history, which is issued ex-professo when the follow-up is to be completed in a planned manner and at the request of the patient, and it is necessary to continue the process with another specialist (usually as a result of a change of address).