Week 6 well child visit soap note

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Patient 7 yr old female who is brought today to the clinic by grandma for an annual exam. Patient is well dress, looks properly nourished and well groomed. Physical assessment performed. No concerns today. Vaccines up to date. Patient is currently in dance class and goes every day. Patient developmental is appropriate for her age. Education: look both ways before crossing the streets Never go with stranger never stay alone without the supervision of an adult in a pool or beach In case of fire action plan created Patient still needs to use the booster sit until turn 8 yrs old F/U after next birthday 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: