Well child SOAP note- TEENAGER 16 y

SOAP notes for teenager 16 year old

ID: Patient’s initials : G.R, Encounter ID: Age : 16 years, 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):

Patient is a healthy year-old 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 she/he need meningococcal vaccine today immunizations as scheduled.

ASSESSMENT ( please add 3 in text citations with References).

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 MENINGOCOCOCAL VAACINATION is due today( intext citations with REFERENCE NEED HERE

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

PLAN (3 in text citations with references)

1-

2-

3-

Medications: dose is need it if prescribed medication

Patient EDUCATION ( Three (#3) in text CITATION with references )

1-

2-

3-

Referral:

Follow-Up:

References: