6.25.19 soap note.docx - Pediatric SOAP Note NP Student Name Kayla Stevens Child\u2019s Initials CC DOB Clinical Date Age 6 months Place of Born Douglas GA

6.25.19 soap note.docx - Pediatric SOAP Note NP Student...

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Pediatric SOAP Note NP Student Name: Kayla Stevens Child’s Initials: CC DOB: 01/02/2019 Clinical Date: 06/25/19 Age: 6 months Place of Born: Douglas, GA Week Soap Project: 6/25/19 Sex: M _X__ F ___ Type of Soap Note: Well child visit __X__ Sick visit ____ SUBJECTIVE Historian: Parent Present Concerns/CC: ROTA, HIB LT, Pedi-rex LT, Prevnar 13-RT"he has to have shots today" Child Profile: (complete the areas listed as appropriate; may omit an area if not appropriate to the client) Activities of Daily Living ( a g e a pp r o p r i at e) : NA S a f e ty Pr act i c e s : Parents are using car seat, have not had infant around large crowds, infant sleeps on back in crib, does practice safety as infant can roll over now, smoke and carbon monoxide detector in home, child safety locks on cabinets Nutrition: Drinks 6oz of Similac advanced every 4 hours. Eats babyfood and tablefood. Does not drink juice. C h a n ge s i n d a y ca r e / s c h ool /a f t e r-s c h oo l ca r e : NA Sleep: Has a regular bedtime routine, and sleeps through the night without feeding. S p o r t s / ph y s ical ac t i vi t y : NA D e v elo p m e n tal History : - Gross and fine motor: Head flexed forward when pulled to a sitting position. Is able to sit up, rolls over both ways. Reaches and grabs; raking grasps. - Cognitive: Responds to affection. Turns towards sounds. - Social/Emotional/Communication: Smiles, laughs, likes to talk and play. SOCIAL: - No smokers in the home. - No concerns regarding postpartum depression. - No major social stressors at home. - No safety concerns in the home. S ex u al H i s t o r y (i f a p p r o p r i at e ) :NA HPI: S: The patient is a 6 month old white male who presents with mother for well examination.The infant is reaching for objects, babbling, sitting up, and crawling. Drinks 6oz of Similac advanced every 4 hours. Eats babyfood and tablefood. Does not drink juice. Denies TB or lead exposure. Denies any health concerns at present. Medications : No prescribed or OTC medications. PMH: Allergies: NKDA Chronic Illnesses/Major traumas: None reported Hospitalizations/Surgeries: Circumcision during hospitalization Immunizations: Up-to-date Revised 5/9/18; 8/9/18; 10/29/18
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Pediatric SOAP Note Family Medical History ( Identify all immediate family members, their age, & health status) Mother: 32-year-old white female with no known health problems.
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  • Summer '17
  • Pediatrics, Rota, Unlabored respirations

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