SOAP NOTE week 6

Name:

Date:

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)

Medications: (List with reason for med )

PMH:

Allergies:

Medication Intolerances: Chronic Illnesses/Major traumas: Hospitalizations/Surgeries: Immunizations:

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

ROS

General

Cardiovascular

Skin

Respiratory

Eyes

Gastrointestinal

Ears

Genitourinary/Gynecological

Nose/Mouth/Throat

Musculoskeletal

Breast

Neurological

Heme/Lymph/Endo

Psychiatric

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

Weight

Temp

BP

Height

Pulse

Resp

General Appearance and parent‐child interaction

Skin

HEENT

Cardiovascular

Respiratory

Gastrointestinal

Breast

Genitourinary

Musculoskeletal

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)

Diagnosis

· 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.

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