week 4 peds soap note. Well child visit

Soap note checklist:

· Did I do the right assignment?

Verify well child Soap note or Focused Soap note

· Did I get a thorough history of present illness?

-Include HPI about diet elimination, sleep patterns?

-If fever- Did I ask how the temperature was taken, what was the last temperature

· Did I put the ages down of at least the Mother /Father

· Did I document proper Review of systems?

-In this section this should not be physical exam findings.

· Do I always include the skin assessment?

-Where on the skin was assessed? _ thorax- bilat UE/ LE

-All Pediatric soap notes should always have the skin exam

· Did I document proper physical exam findings?

-must document physical exam findings per your physical exam textbook-

The word “ normal” is not used

Ensure to specify right left bilateral

Ensure to document all the lymph nodes of the head and e neck exam

The HEEENT section should include

Fontanelles- anterior posterior

Head

Eyes

Eats

Mouth

Tonsil

Throat

Neck

Lymph nodes of head and neck

· For well child exam:

· Did I include a cdc.Gov plotted growth chart with percentiles?

· Head

· Height

· Weight

·

· Did I include 3 differential diagnoses with references for each?

· Did I include a final diagnosis with a reference?

· Is my plan complete?

-Correct dose of medication

-Education on medication side effects

Specific, thorough education—not broad based but specific recommendation

· For my Well child Sopa did I include anticipatory guidance per Bright Futures?

· Did I use at least 3 references with proper APA citation?

· Did proof read for spelling errors ?

Extra resource

https://www.aap.org/en/practice-management/bright-futures

https://www.healthychildren.org/English/family-life/health-management/Pages/Well-Child-Care-A-Check-Up-for-Success.aspx