week 7 focused soap note

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Focused soap note. Use evidence based practice. APA format. Please follow soap notes pearls

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PEDSSOAPnotepearlscopy.docx

PEDS SOAP NOTE PEARLS

· HPI - always include assessment of diet, activity, elimination, sleep

· If has temp always document how temp was take- oral, axilla etc and what was last temp

· If had any meds get name, dose, last time given

· Ensure to include ALL aspects of OLDCARTS

· PE

· Every exam WCC or focused should include a skin assessment. Skin intact to thorax, bilateral UE and LE, no bruising, ecchymosis of skin tears noted.

· Include completes assessment for HEENT

· Head- ensure to examine fontanelles and document if open/closed

· Eyes-ensure to document complete assessment

· Ears-ensure to include cones of light exam

· Nose-ensure to include bilateral nare exam

· Sinus- ensure to include complete sinus exam

· Mouth- ensure to include buccal mucosa, dentition

· Throat- ensure complete exam

· Tonsil- ensure proper grading using tonsil scale

· Lymph nodes-document names of all lymph nodes head and neck and their assessment

· Cardio- ensure have S1, S2, no M/R/G

· Lungs- CTA bilateral UL/LL/laterally, anterior and posterior

· MSK- ensure to document proper strength scale 5+/5+, etc

· Reflexes- ensure to document proper scale 2+/2+, etc

· Assessment

· Need to provide rationale for all diff dx and final dx- how were they ruled in/out

· Plan

· Need detailed patient education- saying educated oh healthy diet not enough- need specifics- exactly what should their diet include

· Ensure to have ER precautions and specifics of when the patient should follow-up and why

· Anticipatory guidance should be included in all WCC- use Bright Futures resources

· All medication should include education on medication side effects

· All WCC need to have growth chart properly documented and plotted

** Details are important- If is was not documented it was not done.**

Week7PEDSSOAPNoteTemplate1.docx

H61.22 | Impacted cerumen, left ear

Patient 10 yr old female who comes in with mom for evaluation of left ear muffled hearing. Patient denies any other associated symptoms including sore throat, recent cold, fever, nausea, vomiting, nasal discharge or problem with right ear. Ear assessment performed. BL TMs unable to assess at this time due to wax build up. Patient BL ears irrigated, using syringe irrigation kit and moderate amount of wax drainage observed from right ear. Severe wax drainage observed left ear. Immediately after irrigation patient verbalized improvement. BL TMs observed, pearly gray, good cone of light. No redness, swelling , or discharge noticed. Education: Do not use anything to clean the ears F/U: In 9 months for annual check up or PRN Subjective, Objective, Assessment, Plan (SOAP) Notes

Student name:

Course:

Patient name (initials only):

Date: Time:

Ethnicity:

Age: Sex:

SUBJECTIVE

CC:

HPI:

Medications:

Past medical history:

Allergies:

Birth hx: (use only on well child visits):

Immunizations:

Hospitalizations:

Past surgical history:

Social history:

Developmental Assessment: (include on well child visit only but may be necessary for problem focused notes)

FAMILY HISTORY

Mother:

MGM:

MGF:

Father:

PGM:

PGF:

REVIEW OF SYSTEMS

General:

Cardiovascular:

Skin:

Respiratory:

Eyes:

Gastrointestinal:

Ears:

Genitourinary/Gynecological:

Nose/Mouth/Throat:

Musculoskeletal:

Breast: Heme/Lymph/Endo:

Neurological:

Psychiatry:

OBJECTIVE (Document PERTINENT systems only, Minimum 3 for problem focused, all systems for well child exam)

Weight: Height: BMI: BP: Temp: Pulse: Resp:

(Insert plotted growth chart below on all well child soap notes)

General appearance:

Skin:

HEENT:

Cardiovascular:

Respiratory:

Gastrointestinal:

Genitourinary:

Musculoskeletal:

Neurological:

Psychiatric:

Labs performed in office the day of visit:

Diagnosis (must complete this section and explain how all differential diagnoses were ruled in or ruled out)

Differential diagnoses:

1. Diagnosis, (ICD 10 code and reference):

2. Diagnosis, (ICD 10 code and reference):

3. Diagnosis (ICD 10 code and reference):

Diagnosis (ICD 10 code and reference):

Plan/therapeutics/diagnostics;

Education provided:

CPT Code:

Anticipatory guidance (well child visit only)

References: