child SOAP note to complete

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  • 3 years ago
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SOAPnotesinachild.docx

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Delete all text in Yellow- these are instructions and not part of the SOAP document.

Well child SOAP note- Child

Requirement:

· APA format

· Intext citation

· References minimun 4 high-level scholarly reference per post within the last 5 years in APA format.

· EACH differential diagnostic gets 1 reference

· Plagiarism free.

· Turnitin receipt.

SOAP notes

ID: Patient’s initials : G.R, Encounter ID: Age : 11 years Gender: female, Ethnicity: Hispanic DOB: . The patient came to the facility with his mother.

The mother is a good reliable history and answered all the questions.

SUBJECTIVE:

CC: “We are here for a well check-up.”

History of Present Illness (HPI):

G.R. is a healthy 11-year-old female presents to the clinic with his mother for a wellness visit. The mother reported that his son has been healthy, she has no concerns. His previous well visit was last year and everything was normal. The mother states that he received all his immunizations as scheduled.

ASSESSMENT ( References need it for the 3 diagnosis given).

1- Encounter for routine child health examination without abnormal findings ( Z100-129) patient is due for wellness check-up. (. ).REFERENCE NEED HERE, no rationals here.

2- Encounter for Immunization:)( Z23 ) Came here for human Papillomavirus (HPV REFERENCE NEED HERE with rationals

3- Dietary counseling and surveillance (Z71.83): ( )REFERENCE NEED HERE with rationals.

Plan (need only 3 with references)

1-

2-

3-

Medications: dose is need it if prescribed medication

Patient Education (ONLY 3, EACH ONE NEED CITATION)

1-

2-

3-

Referral: (USE CITATION HERE)

Follow-Up:

References