6435-Week3SoapNote.docx - Pediatric SOAP Note NP Student Name Stacy Martin Child\u2019s Initials FM DOB Clinical Date Age 15 Place of Born Marianna FL Sex

6435-Week3SoapNote.docx - Pediatric SOAP Note NP Student...

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Pediatric SOAP Note NP Student Name: Stacy Martin Child’s Initials: FM DOB: 08/23/2004 Clinical Date: 12/19/2019 Age: 15 Place of Born: Marianna, FL Week Soap Project: W3 Sex: M ___ F _x__ Type of Soap Note: Well child visit ____ Sick visit __X__ SUBJECTIVE Historian: Parent Present Concerns/CC: “She has been running a fever and this morning is was 103.”. 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) : The child is independent with dressing, brushing her teeth and tying shoes. The child settles for sleep independently. The child sleeps in his own bed. The child feeds self without difficulty. S a f e ty Pr act i c e s : Child sits in the back seat with seat belt on. Knows how to swim without floatation devices. Mother states sunscreen is used, -tobacco/ETOH abuse, -falls, -lead, - TB exposure Nutrition: Mother states that the child drinks 2% milk at least one cup daily. Mother states the child does drink juices and flavored waters. Drinks water and eats a balanced diet. 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 : Enrolled in high school. Sleep: The child sleeps in her bed at night and usually goes to sleep around 9 pm and wakes up at 630 am. S p o r t s / ph y s ical ac t i vi t y : PE at school. No extracurricular D e v elo p m e n tal History : - Gross motor: Hops, skips, swims. - Fine motor: colors inside the lines. - Cognitive: Follows simple and complex directions - Social/Emotional: plays well with other children, somewhat withdrawn regarding personal issues. - Communication: Has an age appropriate vocabulary. 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: The patient is a 15-year-old white female who presents with her mother with the complaint of fever, runny nose, cough, sore throat, vomiting, with associated myalgias for 7 days. They have tried OTC medications for pain/fever such as Acetaminophen, Ibuprofen, and Robitussin. Medications : Acetaminophen, Ibuprofen, Robitussin Fluticasone 50 mcg/ml- 1 spray each nostril once daily x 7 days Loratadine-D 5-120 mg take 1 tablet by mouth daily PMH: Allergies: NKDA Chronic Illnesses/Major traumas: None reported Hospitalizations/Surgeries: None reported Immunizations: Up-to-date Family Medical History ( Identify all immediate family members, their age, & health status) Mother: 35-year-old White female with no known health problems. Father: 39-year- White male with no known health problems. Younger siblings (10 year old and 12 year old younger brothers) no known health problems Revised 5/9/18; 8/9/18; 10/29/18
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Pediatric SOAP Note Social History (complete the areas listed as appropriate; may omit an area if not appropriate to the client) Cu r r e n t li vi n g s it u a t io n / pa r t n e r / m a r i t a l s t a t u s : Lives at home with mother, father, younger siblings E d uc a t io nal le v e l (as appropriate) : Freshman at high school O cc up a t i on a l h i s t o r y (as appropriate) : NA S u b s t an ce u s e / ab u s e (ETOH, tobacco, and marijuana): NA Firearms in home: Father has guns which mother states is stored in a locked safe S a f e ty s t a t u s :
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