wk6 focused peds soap note

Well-child SOAP Note Format     

Demographic Data 

· Age, and gender (must be HIPAA compliant) 

Subjective 

· ___-day/week old infant/child accompanied by ___________ and here for a routine well-child/baby check (and vaccines). Any parental concerns/ questions today? 

· Interval Events/History: 

· Nutrition: 

· Elimination: 

· Sleep: 

· Medications: 

· Allergies: 

· Past Medical 

·

· Pregnancy and delivery? 

· Surgeries, hospitalizations, or serious illnesses to date? 

· Immunizations? 

· Development: (describe as applicable to age) 

·

· Gross motor: 

·

· Fine motor: 

· Cognitive: 

· Social/Emotional: 

· Communication: 

· Social History: 

· Smoking in the home? 

· Family life/structure/dynamics? Primary caregivers? 

· Stressors? 

·  Family History: 

Objective  (Should be a thorough head to toe assessment) 

· Vital Signs/growth measurements (weight, length, head circumference, BMI, BP, HR, etc. if applicable) 

·

· Physical findings listed by body systems, not paragraph form. 

· Highlight abnormal findings 

· Growth Chart Percentages: if applicable 

· Labs/Studies: if applicable 

  Assessment  

· Well-child visit ICD10 code(s) 

Plan 

· Vaccines today: 

· Anticipatory guidance (discussed or covered in the visit)? 

· Health Maintenance 

· Return precautions?