Nursing > SOAP NOTE > NURS 6541 Pediatric SOAP note (All)

NURS 6541 Pediatric SOAP note

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You have a total of three SOAP notes to complete this term. You are required to include:  at least one SOAP that is a well-child exam/School Age (6-11 y/o).  at least one SOAP – infant  ... at least one SOAP-toddler/pre-school age. Please set your SOAP note up in a systematic way. Do not place the entire SOAP note in a narrative paragraph format for reading. You will list each section separately. SUBJECTIVE DATA What the patient/parent tells you, organized in a logical fashion Chief Complaint (CC): Explains why the patient came to the clinic and who is accompanying them (mom, dad, grandparent, sitter, etc) History of Present Illness (HPI): Paint a picture of what is wrong with the patient. You need to start EVERY HPI with age, race, gender. (Example: 12 month old Hispanic male). Must include the 7 attributes of each principal symptom: Review of Systems: Think head to toe. Remember, this is what the patient tells you. (This is not your physical assessment!) For both sick and well-child exams, each area should be addressed. Remember, you are not allowed to use “WNL”. 1.  General Health Mom noticed no problems with appetite, sleep, or activity level. Patient denied or mon reports no fevers, bone pain, night sweats, sick contacts, joint pain, rashes. 2. Skin-reports no rashes, bruises, insect bites, or sores 3. HEENT- reports no problems with oral and nasal pharynx 4. Thorax/Chest- Denies chest pain 5. Respiratory-denies SOB 6. Heart- No reported symptoms 7. GI-Denies nausea, vomiting, or diarrhea 8. Genital 9. Musculoskeletal 10. Neuro/Psychiatric 11. Endocrine 12. Hematologic Health Risks: General review. If you are doing a well exam, include them all: pets, tobacco exposure, TB exposure, lead exposure, immunocompromised, cholesterol risk, car seat/booster/seat belt, adequate fluoride, dental exam, firearms in home secured, helmet use, fire alarms, water safety, etc. (The most common health risk behaviors among adolescents are tobacco use, alcohol use, drug use, behaviors that result in injury or violence, sexual behaviors that result in sexually transmitted infections and pregnancy, poor nutrition, and physical inactivity). [Show More]

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