week 1 SN

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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:

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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)

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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: