Well-child SOAP Note

Demographic Data

x Age, and gender (must be HIPAA compliant)

Subjective

x ___-day/week old infant/child accompanied by ___________ and here for a routine well-child/baby check (and vaccines). Any parental concerns/ questions today?

x Interval Events/History: x Nutrition: x Elimination: x Sleep: x Medications: x Allergies: x Past Medical

R Pregnancy and delivery? R Surgeries, hospitalizations, or serious illnesses to date? R Immunizations? x Development: (describe as applicable to age)

R Gross motor:

R Fine motor: R Cognitive: R Social/Emotional: R Communication: x Social History: R Smoking in the home? R Family life/structure/dynamics? Primary caregivers? R Stressors? x Family History:

Objective (Should be a thorough head to toe assessment)

x Vital Signs/growth measurements (weight, length, head circumference, BMI, BP, HR, etc. if applicable)

R Physical findings listed by body systems, not paragraph form. R Highlight abnormal findings

x Growth Chart Percentages: if applicable x Labs/Studies: if applicable

Assessment

R Well-child visit ICD10 code(s)

Plan

x Vaccines today: x Anticipatory guidance (discussed or covered in the visit)? x Health Maintenance x Return precautions?