wellchild soap note

· Write an entire SOAP for the well child visit that took place during immersion. For the child, please use the history you obtained during your encounter. For the chief complaint of all notes, you will write “well visit.” Please use your AAP Bright Future’s guide as the main resource for this assignment. Note that pediatrics will require more information than most SOAP notes, including percentiles for Ht/Wt/BMI, and developmental history, among other differences.

· Please plot the height, weight, and BMI for your child on a growth chart (samples can be found on CDC) and include the growth chart with your submission.

· Make sure you include a developmental assessment, and for pre-teens and teens, a HEEADSSS assessment.

· Preferably, use the format described at immersion by using one of the templates in week one of the course. Make sure to include an assessment (diagnosis) and plan. Use actual diagnosis terminology. Be sure to use APA format and include references. Review the rubric before you begin working on the assignment.

RB is a 7yr old pt. who presents to the clinic for a routine well child checkup visit with his parents. He is not an established patient. Today he weighs 51.8 lbs and is 122cm tall, as measured in the clinic.

BP: 94/60 P:80 RR:20 T: 98.4F

DOB: 9/18/14

Last check up: LAST YEAR

No hospitalization/surgery

No past hx

No medication

No allergies other than peanuts, asking for refill of epipen

Has pets: 1 dog

Eats fruits and vegetables “eats very good” as per mother. Likes candies

No concerns with developments

1st grade, very sociable, makes friends, plays baseball. No bullying

Flu Shot January

Siblings: 13, 5, 6, 1 years old: no health problems noted

Last Dental Appointment: March

Last Eye Appointment: January

RB plays with siblings, helps with chores, very independent, little bossy, sleeps well, balance with outside games

Safety

Dad lives with them. Stay at home mom

No guns, no relocation, booster seat, buckle up for safety

Bicycle

Swimming pool, lifeguard watching

Lives in a 50-year-old house---screen for lead and asbestos

Grandparents: cancer, hypertension, diabetes

No smoking no etoh and recreational drugs

>Calculate the height and weight percentiles, BMI and BMi percentile using an app or website.

>Is there an immunization record? If so, check it against the immunization schedule (CDC) are any due?

Diagnosis:

1. encounter for well child exam

2. encounter for immunization

3. Allergy to peanuts

>>Offer education about immunization

>>prescribe epipen for allergy to peanuts

>>Subjective: Add CDC immunization schedule applicable to patient.

>>Objective: Plot Growth Chart

All answers to these questions were all normal

Pediatric Interview and Well Child Exam - suggestions

Preschool and School aged (3-12)

INTRODUCTION

	Introduce self to parent.
	Maintain good eye contact with parent.
	Inquire about the reason for the visit.
	Inquire about interval history since the last visit.

PAST MEDICAL HISTORY

	Illnesses
	Exposures to harmful substances
	Accidents or injuries
	Hospitalizations or Surgeries
	Medications (complete with dosages, frequency, and reason)
	Allergies to medications or food (with reaction)

OTHER PEDIATRIC HISTORY

FEEDING HISTORY – EARLY AND MIDDLE CHILDHOOD / ADOLESCENCE

	Appetite
	Types of food/milk eaten and amounts
	Parental attitudes toward eating
	Difficulties or concerns with eating

OTHER PEDIATRIC HISTORY

DEVELOPMENTAL HISTORY & MILESTONES

	General physical growth parameters throughout childhood (growth spurts)
	Concerns with child meeting past developmental milestones
	Sleeping patterns (day and night)
	Any concerns with ritualistic behavior or habits
	Discipline techniques used and effectiveness
	School (academic achievements, social relationships, concerns)
	Peer relationships (concerns, types)
	Sexuality (interactions with opposite sex, knowledge of conception, pregnancy, differences in boys and girls, parental attitude toward sex education, dating patterns)
	Personality (degree of independence, relationships with parents and siblings, imaginary friends, self-image)
	Addresses the “Suicide” component of the HEADSS assessment.
	Addresses the “Home” component of the HEADSS assessment.
	Addresses the “Activities/Employment” component of the HEADSS assessment.

IMMUNIZATIONS

	Current immunization status
	Past reactions to immunizations
	Parental attitude toward immunizations

FAMILY HISTORY

	Medical history of grandparents
	Medical history of parents
	Medical history of siblings
	Other general familial diseases

SOCIAL HISTORY

	Other household members (relationship to patient and age)
	Immediate family members not living in the household
	Childcare arrangements
	Financial resources of family
	Childproofing and safety concerns around house (including gun safety)
	Any recent changes/problems with living/family environments
	Recent travel or relocation
	Pets or exposure to animals
	Drug use (family or patient)
	Alcohol use (family or patient)
	Tobacco use (family or patient)
	Seatbelts/carseats/booster seats. Helmet use. Swimming pool at home?
	Concerns for abuse

NP Student: Communication and Skills

	Verbalizes necessary immunizations at this visit based on CDC recommendations (chart available to students)
	Verbalizes anticipatory guidance with regard to AAP car seat / safety belt guidelines.
	Verbalizes one additional component of age-appropriate anticipatory guidance according to Bright Futures Guidelines.
	Properly charts the patient’s stature for age on the CDC growth chart.
	Properly charts the patient’s BMI for age on the CDC growth chart.
	Properly charts the patient’s weight for age on the CDC growth chart.

SOAP note TEMPLATE

SUBJECTIVE:

ID:

CC: “ “

HISTORY OF PRESENT ILLNESS (HPI):

PAST MEDICAL HISTORY

PAST MEDICAL PROCEDURES

MEDICATIONS

ALLERGIES

FAMILY HISTORY

SOCIAL HISTORY

-SEXUAL/REPRODUCTIVE

-TOBACCO USE/Vaping:

-ALCOHOL USE: social drinker

-DRUG USE:

-MARITAL HISTORY:

-OCCUPATION:

-EXERCISE/DIET:

-SLEEP/STRESS:

IMMUNIZATIONS

SPIRITUAL AFFILIATION

REVIEW OF SYSTEMS:

ONLY DOCUMENT WHAT YOU ASKED ABOUT

DO NOT copy and paste this list or you will have a high “Turn-It-In” score. Students should be able to reword and include only what they asked.

CONSTITUTIONAL: denies fever, chills, and loss of appetite, fatigue, or weight loss

EYES: denies blurred vision, scleral icterus, tunnel vision, discharge, pruritus, edema, and redness (date of last eye exam can go here)

EARS, NOSE, MOUTH/THROAT: denies hearing loss, tinnitus, vertigo, discharge, and earache, denies rhinorrhea, stuffiness, sneezing, and epistaxis, denies allergies, denies pain or difficulty swallowing (date of last dental exam can go here)

CARDIOVASCULAR: denies angina, palpitations, orthopnea, paroxysmal nocturnal dyspnea, edema, or dyspnea.

RESPIRATORY: Denies hemoptysis, wheezing, and shortness of breath, cough, or sputum production.

GASTROINTESTINAL: denies, dysphagia, constipation, abdominal pain, hemorrhoids. Reports rectal bleeding with bright red blood, rectal pain, and reflux and history of rectal cancer.

GENITOURINARY: denies urinary urgency, hesitancy, frequency, polyuria, dysuria, hematuria, incontinence, libido changes, and infection. Women: Denies menstrual changes, vaginal discharge, vaginal dryness or pain, or abnormal bleeding. Men: Denies scrotal pain, penis pain, masses, weak stream or erectile dysfunction

MUSCULOSKELETAL: denies stiffness, joint pain, joint swelling, muscle pain, or decreased ROM.

INTEGUMENTARY/BREAST: Denies pruritus, rashes, stria, lesions, wounds, nodules, tumors, eczema, excessive dryness and/or discoloration. Denies breast pain, soreness, lumps, or discharge.

NEURO: denies seizures, headaches, motor weakness, paresthesias, paralysis, memory loss

PSYCH: denies anxiety, depression, mood changes, body image problems, mania, binges, or suicidal thoughts

ENDOCRINE: Denies heat or cold intolerance, weight changes, polyuria, polydipsia, polyphagia, changes in hair, libido or sexual performance

HEMATOLOGIC/LYMPHATIC: Denies excessive bleeding, easy bruising, petechia. Denies enlarged, swollen, or tender lymph nodes

ALLERGY/IMMUNOLOGY: Denies drug/food/seasonal allergies, denies getting sick more frequently than others, or taking longer to recover

OBJECTIVE:

VITAL SIGNS: P: BP: RR: T: 97.8 SpO2 RA: Pain : /10

Ht : Wt : BMI:

PHYSICAL EXAM: GENERAL survey:

HEENT:

Head

Eyes

Ears

Nose

Throat

Mouth

·

HEART:

RESPIRATORY:

CHEST/BREASTS:

GI:

GU:

LYMPH:

MUSCULOSKELETAL/EXTREMITIES:

SKIN:

NEUROLOGIC:

PSYCHIATRIC:

ASSESSMENT:

Differential Diagnosis:

1. One possible dx with rationale on why you ruled out

2. Another

3. A third (minimum = three)

4. A fourth

FINAL DX: The chosen diagnosis from above

PLAN:

-Diagnostic plan (labs/xrays/EKG etc.)

-Treatment/Therapeutic Plan: Meds, treatments, diet/exercise/etc. recommendation

-Referrals

-Education

-F/U plan