week 5 pediatric soap note

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APA format, evidence based practice. Due in 24 hrs. Previous soap note and feedback from instructor provided.

a year ago
08.06.2025
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PEDSSOAPNoteTemplateweek5.docx
feedbackfocusedWeek3-pedssoapnotetemplate1.docx

PEDSSOAPNoteTemplateweek5.docx

J06.9 | Acute upper respiratory infection, unspecified J30.9 | Allergic rhinitis, unspecified

Patient 13 months old comes in with mom for complains of wet cough that started on 5/23 with decreased activity, voice changed and decreased appetite . Patient voice change ,activity level and appetite resolved. Patient started to have nasal congestion yesterday 5/28/25. Patient mom denies any fever, rash, signs of ear pain. A: nasal congestion noted, ears TMs pearly clear BL, throat not irritated, BL tonsils +1 RUL, RML, RLL, LUL, LLL lung fields clear TX: Increase fluid intake over the counter ibuprofen to treat fever and body aches F/U in 9 months for annual exam or PRN if symptoms worsen

Subjective, Objective, Assessment, Plan (SOAP) Notes

Student name:	Course:
Patient name (initials only):	Date: Time:
Ethnicity:	Age: Sex:
SUBJECTIVE
CC:
HPI:
Medications:
Past medical history:
Allergies:
Birth hx: (use only on well child visits):
Immunizations:
Hospitalizations:
Past surgical history:
Social history:
Developmental Assessment: (include on well child visit only but may be necessary for problem focused notes)
FAMILY HISTORY
Mother:
MGM:
MGF:
Father:
PGM:
PGF:

REVIEW OF SYSTEMS
General:	Cardiovascular:
Skin:	Respiratory:
Eyes:	Gastrointestinal:
Ears:	Genitourinary/Gynecological:
Nose/Mouth/Throat:	Musculoskeletal:
Breast: Heme/Lymph/Endo:	Neurological:
	Psychiatry:
OBJECTIVE (Document PERTINENT systems only, Minimum 3 for problem focused, all systems for well child exam)
Weight: Height: BMI: BP: Temp: Pulse: Resp: (Insert plotted growth chart below on all well child soap notes)
General appearance:
Skin:
HEENT:
Cardiovascular:
Respiratory:
Gastrointestinal:
Genitourinary:
Musculoskeletal:
Neurological:
Psychiatric:
Labs performed in office the day of visit:

Diagnosis (must complete this section and explain how all differential diagnoses were ruled in or ruled out)
Differential diagnoses: 1. Diagnosis, (ICD 10 code and reference): 2. Diagnosis, (ICD 10 code and reference): 3. Diagnosis (ICD 10 code and reference):	Diagnosis (ICD 10 code and reference):
Plan/therapeutics/diagnostics;
Education provided:
CPT Code:
Anticipatory guidance (well child visit only)

References:

PEDSSOAPNoteTemplateweek5.docx

J06.9 | Acute upper respiratory infection, unspecified J30.9 | Allergic rhinitis, unspecified

Subjective, Objective, Assessment, Plan (SOAP) Notes

Student name:	Course:
Patient name (initials only):	Date: Time:
Ethnicity:	Age: Sex:
SUBJECTIVE
CC:
HPI:
Medications:
Past medical history:
Allergies:
Birth hx: (use only on well child visits):
Immunizations:
Hospitalizations:
Past surgical history:
Social history:
Developmental Assessment: (include on well child visit only but may be necessary for problem focused notes)
FAMILY HISTORY
Mother:
MGM:
MGF:
Father:
PGM:
PGF:

REVIEW OF SYSTEMS
General:	Cardiovascular:
Skin:	Respiratory:
Eyes:	Gastrointestinal:
Ears:	Genitourinary/Gynecological:
Nose/Mouth/Throat:	Musculoskeletal:
Breast: Heme/Lymph/Endo:	Neurological:
	Psychiatry:
OBJECTIVE (Document PERTINENT systems only, Minimum 3 for problem focused, all systems for well child exam)
Weight: Height: BMI: BP: Temp: Pulse: Resp: (Insert plotted growth chart below on all well child soap notes)
General appearance:
Skin:
HEENT:
Cardiovascular:
Respiratory:
Gastrointestinal:
Genitourinary:
Musculoskeletal:
Neurological:
Psychiatric:
Labs performed in office the day of visit:

Diagnosis (must complete this section and explain how all differential diagnoses were ruled in or ruled out)
Differential diagnoses: 1. Diagnosis, (ICD 10 code and reference): 2. Diagnosis, (ICD 10 code and reference): 3. Diagnosis (ICD 10 code and reference):	Diagnosis (ICD 10 code and reference):
Plan/therapeutics/diagnostics;
Education provided:
CPT Code:
Anticipatory guidance (well child visit only)

References:

PEDSSOAPNoteTemplateweek5.docx

J06.9 | Acute upper respiratory infection, unspecified J30.9 | Allergic rhinitis, unspecified

Subjective, Objective, Assessment, Plan (SOAP) Notes

Student name:	Course:
Patient name (initials only):	Date: Time:
Ethnicity:	Age: Sex:
SUBJECTIVE
CC:
HPI:
Medications:
Past medical history:
Allergies:
Birth hx: (use only on well child visits):
Immunizations:
Hospitalizations:
Past surgical history:
Social history:
Developmental Assessment: (include on well child visit only but may be necessary for problem focused notes)
FAMILY HISTORY
Mother:
MGM:
MGF:
Father:
PGM:
PGF:

REVIEW OF SYSTEMS
General:	Cardiovascular:
Skin:	Respiratory:
Eyes:	Gastrointestinal:
Ears:	Genitourinary/Gynecological:
Nose/Mouth/Throat:	Musculoskeletal:
Breast: Heme/Lymph/Endo:	Neurological:
	Psychiatry:
OBJECTIVE (Document PERTINENT systems only, Minimum 3 for problem focused, all systems for well child exam)
Weight: Height: BMI: BP: Temp: Pulse: Resp: (Insert plotted growth chart below on all well child soap notes)
General appearance:
Skin:
HEENT:
Cardiovascular:
Respiratory:
Gastrointestinal:
Genitourinary:
Musculoskeletal:
Neurological:
Psychiatric:
Labs performed in office the day of visit:

Diagnosis (must complete this section and explain how all differential diagnoses were ruled in or ruled out)
Differential diagnoses: 1. Diagnosis, (ICD 10 code and reference): 2. Diagnosis, (ICD 10 code and reference): 3. Diagnosis (ICD 10 code and reference):	Diagnosis (ICD 10 code and reference):
Plan/therapeutics/diagnostics;
Education provided:
CPT Code:
Anticipatory guidance (well child visit only)

References:

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