NR 509 Week 6 Pediatric SOAP Note, Complete latest (Spring 2020) template.

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SOAP NOTES TEMPLATE S: Subjective Information the patient or patient representative told you. Initials: DR: Age: 8 years old Gender: Male Height: 4’2” Weight: 90lbs BP: 120/91 HR: 100 ... RR: 28 FVC: 3.91 FEV1: 3.15 FEV1/FVC: 80.5% Temp: 37.2C SPO2: 96% Pain (1-10): 3 Allergies Medication: NKDA Food: No known food allergies Environment: No known environmental allergies History of Present Illness (HPI) Chief Complaint (CC): Cough Onset: 5 days ago Location: Chest Duration: Frequent (every couple of minutes without trigger noted) Characteristics: Wet, productive with clear sputum Aggravating Factors: Unknown triggers Relieving Factors: Cough medicine alleviated the cough for a short amount of time Treatment: Cough syrup today Current Medications Medication Dosage Frequency Length of Time Reason for Use SOAP NOTES TEMPLATE Used Kids Multivitamin Gummies Recommended dosing Daily Unknown Health maintenance Cough Syrup Recommended dosing PRN Unknown Cough treatment Past Medical History (PMHx)— Danny is an 8-year-old male that denies any history of allergies to medications, foods, seasonal, latex or environmental agents. He reports having frequent colds and being diagnosed with pneumonia last year. He takes a daily dose of children’s multivitamin gummies as well as PRN doses of cough syrup to treat episodes of coughing. He reports that his immunizations are up to date and denies any other history of major illnesses (including asthma), hospitalizations, or surgeries. Social History (Soc Hx)— Danny is a 3rd grade student with a reported history of missing school for two weeks last year due to pneumonia. He lives with his mother and father and is cared for by his grandmother while his parents are working. English is the primary language spoken in the home with Spanish as an alternate language utilized. Family History (Fam Hx)— Danny’s mother has type II diabetes, hypertension, hypercholesterolemia, spinal stenosis, and is obese Danny’s father is a smoker (cigars), and has hypertension, hypercholesterolemia, as well as a childhood history of asthma Danny’s grandparent’s history: Maternal— Grandmother: type II diabetes and hypertension Grandfather: Smoker and eczema Paternal— Grandmother: died in a car accident at 52 years of age Grandfather: No known history Review of Systems (ROS): Address all body systems that may help rule in or out a differential diagnosis Constitutional If patient denies all symptoms for this system, check here: Check the box next to each reported symptom and provide additional details. Check if Symptom Details SOAP NOTES TEMPLATE Positive x Fatigue “kind of tired” Weakness Denies Fever/Chills Denies Weight Changes Denies Trouble Sleeping Denies Night Sweats Denies Other Denies Skin If patient denies all symptoms for this system, check here: Denies all symptoms Check the box next to each reported symptom and provide additional details. Check if Positive Symptom Details Itching Rashes Nail Skin Color Other HEENT If patient denies all symptoms for this system, check here: Check the box next to each reported symptom and provide additional details. Check if Positive Symptom Details Diplopia Denies Eye Pain Denies Eye redness Denies Vision changes Denies Photophobia Denies Eye discharge Denies Eye discharge Denies x Earache x2days, right ear Tinnitus Denies Vertigo Denies Hearing Changes Denies Hoarseness Denies x Sore Throat Reports “a little” pain and soreness x Congestion “my cough seems kind of wet and gurgly” x Rhinorrhea “my nose always runs a little, but it is worse since the cough started” SOAP NOTES TEMPLATE Other Denies Respiratory If patient denies all symptoms for this system, check here: Check the box next to each reported symptom and provide additional details. Check if Positive Symptom Details x Cough Frequent coughing without much relief from cough syrup Hemoptysis Denies Dyspnea Denies Dyspnea Denies Pain on Inspiration Denies Other Denies Neuro patient denies all symptoms for this system, check here: Denies all symptoms Check the box next to each reported symptom and provide additional details. Check if Positive Symptom Details Syncope or Lightheadedness Headache Numbness Tingling Sensation Changes RUE LUE RLE LLE Speech Deficits Other Cardiac and Peripheral Vascular If patient denies all symptoms for this system, check here: Denies all symptoms Check the box next to each reported symptom and provide additional details. Check if Positive Symptom Details Chest pain SOB Exercise Intolerance SOAP NOTES TEMPLATE Orthopnea Edema Murmurs Palpitations Faintness Occlusions Claudications PND Other MSK If patient denies all symptoms for this system, check here: Denies all symptoms Check the box next to each reported symptom and provide additional details. Check if Positive Symptom Details Pain Stiffness Crepitus Limited ROM RUE LUE RLE LLE Redness Misalignment Other GI If patient denies all symptoms for this system, check here: Denies all symptoms Check the box next to each reported symptom and provide additional details. Check if Positive Symptom Details Nausea/Vomiting Dysphasia Diarrhea Appetite Change Heartburn Blood in Stool Abdominal Pain Excessive Flatus Food Intolerance Rectal Bleeding SOAP NOTES TEMPLATE Other SOAP NOTES TEMPLATE GU If patient denies all symptoms for this system, check here: Denies all symptom Check the box next to each reported symptom and provide additional details. Check if Positive Symptom Details Urgency Dysuria Burning Hematuria Polyuria Nocturia Incontinence Other PSYCH If patient denies all symptoms for this system, check here: Denies all symptoms Check the box next to each reported symptom and provide additional details. Check if Positive Symptom Details Stress Anxiety Depression Suicidal/Homicidal Ideation Memory Deficits Mood Changes Trouble Concentrating Other: GYN If patient denies all symptoms for this system, check here: Denies all symptoms Check the box next to each reported symptom and provide additional details. Check if Positive Symptom Details Rash Discharge Itching Irregular Menses Dysmenorrhea Foul Odor SOAP NOTES TEMPLATE Amenorrhea LMP Contraception Other: Hematology/Lymphatics If patient denies all symptoms for this system, check here: Denies all symptoms Check the box next to each reported symptom and provide additional details. Check if Positive Symptom Details Anemia Easy bruising/bleeding Past Transfusions Enlarged/tender lymph node(s) Blood or lymph disorder Other: Endocrine If patient denies all symptoms for this system, check here: Denies all symptoms Check the box next to each reported symptom and provide additional details. Check if Positive Symptom Details Abnormal growth Increased appetite Increased thirst Thyroid disorder Heat/cold intolerance Excessive sweating Diabetes Other: O: Objective Information gathered during the physical examination by inspection, palpation, auscultation, and percussion. If unable to assess a body system, write “Unable to assess”. Document pertinent positive and negative assessment findings. Body System Positive Findings Negative Findings SOAP NOTES TEMPLATE General Patient is AAOx4, well groomed, interactive and cooperative, and communicates appropriately based on age and educational status. Skin Skin pink, warm, dry, and intact. There is no tenting. Hair is evenly distributed. HEENT **For abnormal findings see bolded sections of the assessment in the next column** Face and head are normocephalic and symmetrical. Inspection Bilateral eyes/orbital area:  No visible abnormalities  Sclera—white  Conjunctiva—pink/moist  Conjunctival discharge—N/A Bilateral nares:  No visible abnormalities  Pink and patent with clear drainage Ears:  Right auditory canal o Erythemic  Right tympanic membrane o Erythemic o No other visible abnormalities o Cone of light 5:00  Discharge o None  Left auditory canal o Pink  Left tympanic membrane o Pearly gray o No visible abnormalities o Cone of light 7:00  Discharge o None Mouth and throat:  Oral mucosa o Pink and moist  Tonsils o Erythemic  Posterior oropharynx o Erythemic o Cobblestoning  Post nasal drip o None SOAP NOTES TEMPLATE Neck:  Symmetrical o No abnormalities Chest:  Symmetrical o No abnormalities Palpated Sinuses:  Frontal o No tenderness  Maxillary o No tenderness Lymph nodes:  Cervical o Palpable nodes on the right side  Supraclavicular o No palpable nodes  Axillary o No palpable nodes Fremitus:  Bilaterally symmetrical with expected fremitus Auscultation Breath sounds:  Clear and present in all lung fields without evidence of adventitious sounds Bronchoscopy:  Negative Heart sounds:  S1 and S2 audible without any extra sounds Percussion  Chest wall o All areas resonant without any areas of dullness Respiratory Frequent cough throughout assessment encounter. Breath sounds:  Clear and present in all lung fields without evidence of adventitious sounds Bronchoscopy:  Negative Neuro Assessment not SOAP NOTES TEMPLATE performed at this time Cardiovascular Heart sounds:  S1 and S2 audible without any extra sounds [Show More]

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