Pediatric SOAP NoteNP Student Name: Kayla Stevens Child’s Initials: ksDOB: 04/1/04Clinical Date: 05/21/19Age: 13Place of Born: Douglas, GAWeek Soap Project: 05/21/19Sex: M _X__F ___Type of Soap Note:Well child visit ___Sick visit _X___SUBJECTIVEHistorian: Parent and childPresent Concerns/CC: “my toe hurts”Child Profile:(complete the areas listed as appropriate; may omit an area if not appropriate to the client)Activities of Daily Living(ageappropriate): The patient feeds, clothes, dresses himself attends school, keeps a tidy room.SafetyPractices: Uses seat belt, no guns in the homeNutrition: Eats three to four meals a day from a variety of food groups. Drinks about 2 sodas per dayChangesindaycare/school/after-schoolcare: NASleep:has a regular sleep routine during school months, likes to stay up late at night. Sports/physicalactivity: Plays baseball in the spring. DevelopmentalHistory: - Gross and fine motor: Appropriate- Cognitive: Takes honors classes when in school does very well with grades. - Social/Emotional/Communication: has lots of friends that he socializes with regularly. SOCIAL:-Denies cigarettes, drugs, and Alcohol. SexualHistory(ifappropriate): Not sexually active. HPI: The patient is a 13 yo white male who presents with mother for c/o redness and pain to L great toe. States that they thought it was aningrown toenail and he was picking at the toe. States he has had a low-grade temperature. Denies any other health concerns at present. Medications: No prescribed or OTC medications.PMH:Allergies: NKDAChronic Illnesses/Major traumas: None reported Hospitalizations/Surgeries: Circumcision during hospitalization Immunizations: Up-to-date Family Medical History (Identify all immediate family members, their age, & health status)Mother: 44-year-old white female with HTNFather: 48-year- white male with CAD, and HTN.Younger sibling (6, female)- no known health problems Revised 5/9/18; 8/9/18; 10/29/18
Pediatric SOAP NoteSocial History (complete the areas listed as appropriate; may omit an area if not appropriate to the client)Currentlivingsituation/p-artner/maritalstatus:Lives at home with mother and father and sister.
- Summer '17
- Toe, Unlabored respirations