Week 6 well child visit soap note

Student name:

Course: NURS 685L Primary Care Pediatric Patient

Patient name (initials only): L.J

Date: 05/29/2025 Time: 09:30 AM

Ethnicity: African American

Age: 9 years Sex: Female

SUBJECTIVE

CC: “My daughter is here for her yearly check-up,” stated by the mother.

HPI: A 9-year-old African American female presents for her annual well-child visit, accompanied by her mother, with no complaints or acute concerns reported. Patient overall health is described as excellent by her mother, with normal appetite, growth, and activity level. The child sleeps at least 8 hours each night with a consistent bedtime routine. Diet includes a variety of fruits, vegetables, lean proteins, and whole grains; no dietary eliminations are currently in place or medically necessary. She exercises at least 30 minutes, three times per week.

Medications: None

Past medical history: No chronic illnesses or significant past medical concerns.

Allergies: No known drug or food allergies.

Birth hx: (use only on well child visits): Full-term vaginal delivery at 40 weeks gestation without complications. Birth weight 7 lbs 2 oz. No NICU stay. Met all newborn milestones.

Immunizations: Up to date per CDC schedule; received all required vaccines through age 4.

Hospitalizations: None

Past surgical history: None

Social history: Lives with both parents and one younger sibling in a single-family home. Attends school full-time with good academic performance. Engages in regular physical activity. Screen time for non-educational use is limited to under 2 hours per day. No exposure to tobacco or substance use in the home. Family emphasizes healthy eating, safety practices, and routine dental and medical care.

Developmental Assessment: (include on well child visit only but may be necessary for problem focused notes)

Age-appropriate gross motor skills (runs, jumps, rides a bike)

Fine motor skills intact (writes legibly, uses utensils properly)

Language skills appropriate (reads and communicates clearly in full sentences)

Cognitive development on track (performs well in school, solves age-appropriate problems)

Socially appropriate interactions (engages with peers, follows rules, shows empathy)

FAMILY HISTORY- Family Hx: Needs ages Mother/Father-feedbakc here previously provided

Mother: Healthy, no chronic illnesses reported

MGM: History of hypertension

MGF: Type 2 diabetes

Father: Healthy, no known medical conditions

PGM: History of asthma

PGF: No known significant medical history

REVIEW OF SYSTEMS

General: The mother reported no fever, changes in weight, exhaustion, or nocturnal sweats.

Cardiovascular: No palpitations, cyanosis, or swelling reported.

Skin: No reports of edema, cyanosis, or palpitations were recorded.

Respiratory: No cough, wheezing, shortness of breath, or recent infections.

Eyes: Denies redness, discharge, or altered vision were made.

Gastrointestinal: No vomiting, diarrhea, constipation, or abdominal pain.

Ears: No issues with hearing, ear discomfort, or discharge.

Genitourinary/Gynecological: No issues with urination, denies vaginal discharge

Nose/Mouth/Throat: No mouth ulcers, sore throats, or congestion in the nose.

Musculoskeletal: No joint pain, swelling, or limitation of movement.

Breast: denies any abnormal breast growth, nipple discharge, or lumps

. Heme/Lymph/Endo: No easy bruising, bleeding, or swollen lymph nodes.

Neurological: No weakness, headaches, or seizures.

Psychiatry: No behavioral changes, anxiety, or mood concerns reported.

OBJECTIVE (Document PERTINENT systems only, Minimum 3 for problem focused, all systems for well child exam)

Weight: 43 kg Height: 54 in BMI: 22.9

BP: 102/64 mmHg Temp: 98.6°F (oral) Pulse: 88 bpm Resp: 18 breaths/min

General appearance: Alert, active child, appropriate interaction for age, no distress observed.

Skin: Examined over thorax, bilateral upper and lower extremities; skin warm, intact, without rashes, lesions, or bruising.

HEENT:

Head: symmetrical, atraumatic, and normocephalic.

Eyes: Equal, round pupils that are responsive to light and accommodation; extraocular movements unharmed; conjunctivae pink and discharge-free; visual acuity remarkably normal for age. Snellen exam 20/20- Specify right/left or bilateral, This feedback was previously provided

Cardiovascular: Regular rate and rhythm, no murmurs, no rubs or gallops. Peripheral pulses palpable and symmetrical in upper and lower extremities. Need to include S1, S2- This feedback was previously provided

Respiratory: Clear breath sounds. Anterior RUL, LUL,RML, RLL, LLL clear. Posterior LUL, RUL, LLL, RLL clear no wheezes, rales, or rhonchi; chest wall symmetric movement with normal respiratory effort BL

Gastrointestinal: Abdomen soft, nondistended, no masses, no bulges, no tenderness; RLQ, RUQ, LUQ and LLQ bowel sound present. No bruits noted during auscultation

Umbilicus: midline and inverted, no signs of inflammation or hernia

Genitourinary: External genitalia normal, no erythema or discharge noted.

Musculoskeletal: Full range of motion in all extremities, no deformities, swelling, or tenderness. +2 reflexes. Upper and lower extremity 5/5 strength BL.No signs of scoliosis or lordosis

Neurological: Alert, appropriate responses for age, normal tone and strength, cranial nerves grossly intact.

Psychiatric: Appropriate mood and behavior, interacts well with caregiver and examiner, no signs of distress or anxiety.

Labs performed in office the day of visit: None during this visit.

Diagnosis (must complete this section and explain how all differential diagnoses were ruled in or ruled out)

Differential diagnoses:

1. Developmental Delay, Unspecified (R62.50)

The child met all age-appropriate developmental milestones in the areas of gross motor, fine motor, speech, social, and cognitive development as assessed during the visit and reported by the caregiver (Khan & Leventhal, 2023).

2. Failure to Thrive (R62.51)

The child’s weight, height, and BMI plotted within normal percentiles, and there are no signs of weight loss, poor intake, or parental concern regarding nutrition or appetite (Smith et al., 2023).

3. Encounter for immunization (Z28.3)

Patient immunization is up to date, based on CDC guidelines (CDC, 2025).

Diagnosis (ICD 10 code and reference):

Encounter for routine child health examination without abnormal findings (Z00.129)

The final diagnosis of Z00.129 was selected because the child is presenting for a routine well-child exam without any signs, symptoms, or abnormal findings (Aharon, 2022). The physical exam was unremarkable, growth parameters were within normal percentiles, developmental milestones were age-appropriate, and immunizations are up to date.

Plan/therapeutics/diagnostics.

No medications prescribed at this visit.

Education provided:

limit screen time <2 hours/day, sleep ≥8 hours/night, exercise ≥30 minutes 3x/week, dental hygiene twice daily, and home safety (smoke detectors, street safety).

Continue age-appropriate immunizations per CDC schedule.

Schedule next well-child visit in 1 year or PRN.

CPT Code: 99392

Anticipatory guidance (well child visit only)

Safe electronic use: put family computer in easily seen place, monitor computer use, install safety filter, use strong passwords, educate child on not given out personal information online.

Emphasize balanced diet and physical activity. Encourage your child to do new activities, like swimming, dancing, or any sports. Encourage child to help at home and in the community.

Get involve in your child activities, school and get to know his friends. Supervise activities with peers

Reinforce importance of regular dental visits. Two times a year. Brush teeth 2 minutes twice a day and floss once.

Discuss safety precautions at home and outdoors. If pools around or in the house educate child to never stay alone in the pool without the supervision of an adult.

School attendance is important, get involve with instructors and student activities. Create a quiet space for homework

Encourage consistent sleep routine.

Car safety: the backseat is the safest place to ride

When riding bicycle use helmets and pads

Remove firearms from home if necessary or store unloaded and locked with ammunition separate (Bright Futures Guidelines, 2017).