Assignment: Pediatric SOAP Note – yearly exam and immunization update

M  x_

F ___

Well child visit __x__

Sick visit ____

Present Concerns/CC: (Reason given by the patient for seeking medical care “in quotes”)

Activities of Daily Living (age appropriate): (include feeding, sleeping, bathing, dressing, chores, etc.)

Safety Practices:

Changes in daycare/school/after-school care:

Sports/physical activity:

Developmental History: (provide a history of development over the child’s lifespan. If child is 1y/o or younger, provide birth history also)

Sexual History (if appropriate):

Allergies:

Chronic Illnesses/Major traumas:

Hospitalizations/Surgeries:

Immunizations: (vaccine & date given; use Up-to-date unless the child is < 1y/o or has not been compliant)

Current living situation/partner/marital status:

Educational level (as appropriate):

Occupational history (as appropriate):

Substance use/abuse (ETOH, tobacco, and marijuana):

Firearms in home:

Safety status:

(Do not omit any body system & remember this is a child not an adult)

(Attach growth chart with height/weight/head circumference plotted & noting percentiles; attach these forms at the end of your SOAP note; include pertinent positives & negatives)

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1.      Include at least three differential diagnoses with ICD-10 codes. (Includes Primary dx and 2 differentials)

2.      Briefly DEFINE each diagnosis supported with evidence-based literature. Also, support each diagnosis with client’s PE evidence and identify the client’s pertinent positives and negatives.

3.      Be sure to cite your EB support and include them on the reference list (place at end of plan).

Final/Primary Diagnosis (es):

PLAN: (include education)

1.      Plan: Treatment plan should be for the Primary Diagnosis and based on EB literature.

2.      Include EB rationale for all aspects of your treatment plan:

a.      Vaccines administered this visit & vaccine administration forms given

b.      Medication-include dosage amounts and mg/kg for drug

c.      Laboratory tests ordered

d.      Diagnostic tests ordered

e.      Non-pharmaceutical treatments

f.        Patient/Family education including preventive care

g.      Follow-up appointment with detailed plan of f/u

h.      Anticipatory guidance for next well child visit (be sure to include exactly what you discussed during visit; review Bright Futures website for this section)

·        Overall feel of the visit

·        Your strengths

·        Your weaknesses

·        Areas for improvement

M x_

F ___

Well child visit __x__

Sick visit ____

Present Concerns/CC: “yearly exam and immunization update.”

Activities of Daily Living (age appropriate): He is generally a pleasant child. Feeds on a well-balanced diet and drinks plenty of water after every meal, and milk with meals. He dresses appropriately on his own but with minimal help on buttons and zips. He sleeps at night in his own bed for about 8 hours.

Safety Practices: All his baths are always supervised. The pool and hot tub are kept safe. He is normally supervised when playing outside.

Changes in daycare/school/after-school care: He is taken care of mostly by a stay at home mom.

Sports/physical activity: He plays with his toys after school, including a tennis ball.

Developmental History: He can go upstairs on his own. He can stand on one foot for about 5 seconds. He can kick a ball forward. His hand and finger skills are quite impressive as he can draw circles and squires. His language is also improving as he understands the concept of “same” and “different.” His cognitive abilities are improved as he can correctly name some colors. He is also able to socialize through playing with other children.

Sexual History (if appropriate): None

Allergies: NKDA

Chronic Illnesses/Major traumas: None

Hospitalizations/Surgeries: No hospitalization or surgical history reported.

Immunizations: Up to date (DTaP x 5, Hep-A x2, Hep-B x3, HIB x4, MMR x2, PCV7 x4, IPV x4, VZV x2, FLU x2)

(Attach growth chart with height/weight/head circumference plotted & noting percentiles; attach these forms at the end of your SOAP note; include pertinent positives & negatives)

Movement: able to stand on one foot for about 5 seconds and can hop perfectly.

Hand and Finger skills: able to use age-appropriate scissors and draw several shapes.

Emotional and social skills: understand the idea of mine and his and is also friendly.

Cognitive: can correctly name familiar colors

Language: can answer simple questions and even say his name and age

The physician uses several milestones of development to determine whether the child’s development is appropriate with his age (In McInerny, & American Academy of Pediatrics, 2017).

PLAN:

·       Return to the clinic after one year for a five-year-old well-child examination and immunization.

·       Vaccines administered this visit: none

·       vaccine administration forms given: none

·       Medication: none

·       Laboratory tests ordered: none

·       Diagnostic tests ordered: none

·       Non-pharmaceutical treatments: none

·       Patient/Family education and Anticipatory guidance for the next well-child visit (van et al., 2015):

ü  Communication and Language Skills: strings four or more words together to construct a sentence.

ü  Movement and Physical Development: try to walk upstairs and downstairs with alternating feet. Try to catch a ball with both arms fully outstretched.

ü   Social and Emotional Development: give the name of one or two of your friends. Name a game liked by your friend.

ü  Cognitive Skills: knowing your first and last name, and your age. Take part in pretend play.

·       When to Talk to see a Doctor: all children develop at their own pace, but there is a standard way in which children of a given age group are expected to grow. Report to the doctor in case your child (In McInerny, & American Academy of Pediatrics, 2017):

ü  Is unable to speak or construct a full sentence.

ü  has severe anxiety or depression

ü  is unable to make strokes with a pencil or crayon

ü  Additionally, if you notice that your child has lost some of the skills that he once had or shows weakness on one body side, inform your physician (In Hagan, In Shaw, & In Duncan, 2017).