week6

SOAPcomprehensivetemplate-pediatrics.pdf

PEDIATRIC Comprehensive SOAP Template

Patient Initials: _______ Age: _______ Gender: _______ SUBJECTIVE DATA: Chief Complaint (CC): Be brief (in a few words) state why patient is here

History of Present Illness (HPI): This is the symptom analysis section of your note. Thorough documentation in this section is essential for patient care, coding, and billing analysis. Paint a picture of what is wrong with the patient. You need to start EVERY HPI with age, race, and gender (e.g., 34-year-old AA male). You must include the seven attributes ofeach principal symptom in paragraph form not a list.: Location, Onset, Character, Associated signs and symptoms, Timing, Exacerbating/ relieving factor, Severity

Medications: Include over-the-counter, vitamin, and herbal supplements. List each one by name with dosage and frequency.

Allergies: Include specific reactions to medications, foods, insects, and environmental factors. Identify if it is an allergy or intolerance.

Past Medical History (PMH): Include illnesses (also childhood illnesses),

hospitalizations. Past Surgical History (PSH): Include dates, indications, and types of operations. Personal/Social History: Include tobacco use, alcohol use, drug use, patient’s

interests, ADL’s and IADL’s if applicable, and exercise and eating habits. Who does the child live with? Does the child attend day care or school? How is the child doing at school? What grade? Discuss the child’s environment and applicable factors such as whether the child attends day care, do parents smoke around the child, bedtime routines, primary caregiver in home etc.

Sexual/Reproductive History: If applicable, include obstetric history, menstrual

history, methods of contraception, sexual function, and risky sexual behaviors. Immunization History: Family History: Include history of parents, grandparents, siblings, and children. Birth/newborn history

Developmental Milestones: (whether met or not for current visit’s age) These

may include fine/gross motor milestones, social and emotional milestones, language/communication milestones, cognitive milestones (learning, thinking, problem-solving):

Nutritional/voiding history: child’s nutritional intake. Breast feeding? Bottle? What

does the child eat/drink? Any issues with producing urine or stool? Lifestyle Risk Assessment: For adolescents, use HEADSS or CRAFFT interview. Review of Systems: From head-to-toe, include each system that covers the Chief

Complaint, History of Present Illness, and History (this includes the systems that address any previous diagnoses).Remember that the information you include in this section is based on what the patient tells you so ensure that you include all essentials in your case (refer to Chapter 2 of the Sullivan text).

General: Include any recent weight changes, weakness, fatigue, or fever, but do not restate HPI data here.

HEENT: Neck: Breasts: Respiratory: Cardiovascular/Peripheral Vascular: Gastrointestinal: Genitourinary: Musculoskeletal: Psychiatric: Neurological: Skin:

Hematologic: Endocrine: Allergic/Immunologic:

OBJECTIVE DATA: From head-to-toe, includewhat you see, hear, and feel when doing your physical exam. You only need to examine the systems that are pertinent to the CC, HPI, and History unless you are doing a total H&P- only in this course. Do not use “WNL” or “normal.” You must describe what you see.

Physical Exam: Vital signs: Include vital signs, ht, wt, ht percentile, wt percentile (bp or head

circumference depending on age of pt) General: Include general state of health, posture, motor activity, and gait. This may also

include dress, grooming, hygiene, odors of body or breath, facial expression, manner, level of consciousness, and affect and reactions to people and things.

HEENT Neck Lungs/chest Heart/peripheral vascular Peripheral Vascular Abdomen Genitourinary: Musculoskeletal: Neurological: Skin: Psych:

Diagnostics: Include any labs, x-rays, or other diagnostics that are needed to develop the differential diagnoses. ASSESSMENT: List your priority diagnosis (es). For each priority diagnosis, list at least three differential diagnoses, each of which must be supported with evidence and guidelines. For holistic care, you need to include previous diagnoses and indicate whether these are controlled or not controlled. These should also be included in your treatment plan. Include well-child as one of the diagnoses PLAN: Include additional laboratory and diagnostic tests, consults, therapeutic modalities, health promotion patient education as well as disposition/follow up instructions as they pertain to your patients’ assessment. Include “treatment” plan for the well child as well. Treatment Plan: If applicable, include both pharmacological and non-pharmacological

strategies, alternative therapies, follow-up recommendations, referrals, consultations, and any additional labs, x-ray, or other diagnostics. Support the treatment plan with evidence and guidelines.

Health Promotion: Include exercise, diet, and safety recommendations, as well as any

other health promotion strategies for the patient/family. Support the health promotion recommendations and strategies with evidence and guidelines.

Disease Prevention: As appropriate for the patient’s age, include disease prevention

recommendations and strategies such as fasting lipid profile, mammography, colonoscopy, immunizations, etc. Support the disease prevention recommendations and strategies with evidence and guidelines.

REFLECTION: Document what you learned from this experience? Any ah-ha’s? You are required to include at least three evidence-based peer-reviewed journal articles or evidenced based guidelines which relates to this case to support your diagnostics and differentials diagnoses. Be sure to use correct APA 6th edition formatting.

REFERENCE LIST ________________________ Preceptor Signature and Date Signature is REQUIRED for this assignment.