patient encounters

PEDIATRIC FILLABLE SOAP NOTE TEMPLATE

1 | P E D I A T R I C S O A P N O T E

STUDENT NAME: DATE OF ASSIGNMENT: Patient Initials: Date of Encounter:

Sex: Age/DOB/Place of Birth:

SUBJECTIVE Historian: Present Concerns/CC: Reason given by the patient for seeking medical care “in quotes” Child Profile: (Sexual History (If appropriate); ADLs (age appropriate); Safety Practices; Changes in daycare/school/after-school care; Sports/physical activity; Developmental Hx)

HPI: (must include all components – OLD CARTS) Medications: (List with reason for meds) PMH: Allergies: Medication Intolerances: Chronic Illnesses/Major traumas: Hospitalizations/Surgeries: Immunizations:

PEDIATRIC FILLABLE SOAP NOTE TEMPLATE

2 | P E D I A T R I C S O A P N O T E

Family History (please identify all immediate family) Social History (Education level, occupational history, current living situation/partner/marital status, substance use/abuse, ETOH, tobacco, and marijuana. Safety status) Review of Systems (ROS)

General Cardiovascular

Skin Respiratory

Eyes Gastrointestinal

Ears Genitourinary/Gynecological

Nose/Mouth/Throat Musculoskeletal

Breast Neurological

Heme/Lymph/Endo Psychiatric

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3 | P E D I A T R I C S O A P N O T E

OBJECTIVE (plot height/weight/head circumference along with noting percentiles) Attach growth chart Weight Temp BP

Height Pulse Resp

OBJECTIVE (Physical Examination)

General Appearance and parent-child interaction

Skin

HEENT

Cardiovascular

Respiratory

Gastrointestinal

Breast

Genitourinary

Musculoskeletal

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4 | P E D I A T R I C S O A P N O T E

Neurological

Psychiatric

In-house Lab Tests – document tests (results or pending)

Pediatric/Adolescent Assessment Tools (Ages & Stages, etc) with results and rationale For adolescents (HEADSSSVG Assessment)

ASSESSMENT (Diagnosis – 3 Differentials and Primary)  Include at least three differential diagnoses with ICD-10 codes. (Includes Primary dx and 2

differentials)  Document Evidence based Rationale for ROS and each differential with pertinent

positives and negatives  Primary diagnosis

 Is #1 on list of differentials  Evidence for primary diagnosis should be supported in the Subjective and Objective

exams. 1)

2)

3)

PEDIATRIC FILLABLE SOAP NOTE TEMPLATE

5 | P E D I A T R I C S O A P N O T E

PLAN including education PLAN including education

 Plan: Treatment plan should be for the Primary Diagnosis and based on EB literature.  Include EB rationale for all aspects of your treatment plan:

 Vaccines administered this visit  Vaccine administration forms given  Medication-amounts and mg/kg for medications  Laboratory tests ordered  Diagnostic tests ordered  Patient education including preventive care and anticipatory guidance  Non-medication treatments

Follow-up appointment with detailed plan of f/u

*ALL references must be Evidence Based (EB)

1. STUDENT NAME:
2. DATE OF ASSIGNMENT:
3. Patient Initials:
4. Date of Encounter:
5. Sex:
6. AgeDOBPlace of Birth:
7. Historian Present ConcernsCC Reason given by the patient for seeking medical care in quotes:
8. Child Profile Sexual History If appropriate ADLs age appropriate Safety Practices Changes in daycareschoolafterschool care Sportsphysical activity Developmental Hx:
9. HPI must include all components OLD CARTS:
10. Medications List with reason for meds:
11. PMH Allergies Medication Intolerances Chronic IllnessesMajor traumas HospitalizationsSurgeries Immunizations:
12. Family History please identify all immediate family:
13. Social History Education level occupational history current living situationpartnermarital status substance useabuse ETOH tobacco and marijuana Safety status:
14. General:
15. Cardiovascular:
16. Skin:
17. Respiratory:
18. Eyes:
19. Gastrointestinal:
20. Ears:
21. GenitourinaryGynecological:
22. NoseMouthThroat:
23. Musculoskeletal:
24. Breast:
25. Neurological:
26. HemeLymphEndo:
27. Psychiatric:
28. Weight:
29. Temp:
30. BP:
31. Height:
32. Pulse:
33. Resp:
34. General Appearance and parentchild interaction:
35. Skin_2:
36. HEENT:
37. Cardiovascular_2:
38. Respiratory_2:
39. Gastrointestinal_2:
40. Breast_2:
41. Genitourinary:
42. Neurological_2:
43. Psychiatric_2:
44. Inhouse Lab Tests document tests results or pending:
45. PediatricAdolescent Assessment Tools Ages Stages etc with results and rationale For adolescents HEADSSSVG Assessment:
46. 1 2 3:
47. PLAN including education PLAN including education Plan Treatment plan should be for the Primary Diagnosis and based on EB literature Include EB rationale for all aspects of your treatment plan Vaccines administered this visit Vaccine administration forms given Medicationamounts and mgkg for medications Laboratory tests ordered Diagnostic tests ordered Patient education including preventive care and anticipatory guidance Nonmedication treatments Followup appointment with detailed plan of fuRow1:
48. Musculoskeletal_2:Pediatric SOAP Note
    

    Patient Initials: M.R	Date of Encounter: 05/03/2019
    Sex: Female	Age/DOB/Place of Birth: 15years old/ 10/08/2003
    SUBJECTIVE
    Historian: Mother Present Concerns/CC: “We have an appointment today for my daughter wellness checkup and update immunizations.”
    Child Profile: MR is a Fifteen years old Hispanic female patient who comes to the clinic today accompanied by her mother for a routine wellness annual exam and immunizations. MR lives with her biological parent’s and was delivery through a normal vaginal birth, and the pregnancy was full term without complications. MR does not have a history of chronic diseases, reports feeling well since the last consult and have proper growth and developmental state. The patient states that she sees her periods every month and they last for three days and denies any sexual activity. Patient’s mother inquires about what vaccines the child needs at this time.
    HPI: MR is a 15 years old teenager brought to the clinic today by her mother for her annual wellness exam. Pt’s mother denies any child history of chronic disease, complication or any concern at this time. The mother reports no previous injuries that have required medical attention and update immunizations.
    Medications: Tylenol 500mg every eight hours as need it during menstrual periods.
    PMH: · Allergies: NKA reported · Medication Intolerances: None · Chronic Illnesses/Major traumas: no reported · Hospitalizations/Surgeries: hospitalized for two days due apendicectomy five years ago. · Immunizations: Up to date
    Family History Both parents are alive and healthy. Mother 35 years old without Hx of any disease and father 38 years old, Obese. Pt has a little sister age five who is active and healthy as well. Pt grandparents are alive and suffer from some chronic diseases like Maternal grandmother has COPD and hypertension, and maternal grandfather is recovering from CVA. The paternal grandmother and father are healthy since now.
    Social History The teen lives with both parents in a nuclear family with good social/financial status. None of the parent’s smoke or consumes alcohol or any drugs. The patient reports that she is not sexually active and is attending high school with good grades. Pt denies the use of recreational drugs. The patient has a great support system from the parents and the rest of the family. Pt states that have excellent communication with her mother.
    ROS
    General Pt well nourished very healthy who has good growth and development for her age. No weight changes. No fever, fatigue, chills, night sweats, or lethargy.	Cardiovascular Patient denies any history of murmur or cardiac issues, no edema, or orthopnea at this time.
    Skin Denies delayed healing, rashes, eczemas, lumps, bruising, itching, dryness, bleeding or skin discolorations, any changes in lesions or moles. .	Respiratory Negative for dyspnea, cough, wheezing, or tachypnea
    Eyes Symmetric. Parent denies eye redness, or drainage.	Gastrointestinal Negative for nausea, vomiting, diarrhea or constipation.
    Ears Patient denies ear pain, or problems with hearing or discharge.	Genitourinary/Gynecological Denies urgency, frequency, burning sensation during urination, and change in color of the urine. No vaginal discharge pampers.
    Nose/Mouth/Throat No symptoms of nasal discharge, congestion, nose bleed, sinus pain, post nasal drip, difficulty in swallowing, and mouth ulcers	Musculoskeletal Negative for back pain. Denies joint swelling, stiffness or pain, fracture history.
    Breast Patient denies breast tenderness and lumps.	Neurological Alert and orient in time, place and person. Good psychomotor development for her age. No history of seizures and other neurologic alterations.
    Heme/Lymph/Endo Negative for bruising, blood transfusion history, night sweats, swollen glands, increase thirst, increase hunger, cold or heat intolerance.	Psychiatric Denies sleeping difficulties, or any previous psychiatric disease. Doing well at school. Good attention span.
    OBJECTIVE Height: 155cm Weight:110 Pounds BMI:20.8 Growth Chart (Between 50-75 percentile (61th)
    Weight 110 lbs.	Temp 98.5 F	BP 104/62 mmHg
    Height 155cm	Pulse 65 bpm	Resp 17 x min
    General Appearance and parent‐child interaction: Teen appears to be well-nourished, in no distress. Cooperative for the exam, interacting appropriately with examiner and mother. Normal weight, healthy, well-developed, alert and oriented, on no distress. Well groomed, pleasant, answers questions appropriately.
    Skin Skin is appropriate for ethnicity; warm, dry and intact. Negative of rashes or lesions. Good skin turgor on examination.
    HEENT Head:…