Pediatric SOAP Note NP Student Name: Stacy Martin Child’s Initials: A.S. DOB: 11/2/2018 Clinical Date: 1/27/20 Age: 15 months Place of Born: Marianna, FL Week Soap Project: W8 Sex: M ___ F _x__ Type of Soap Note: Well child visit __x__ Sick visit ____ SUBJECTIVE Historian: Patient and Mother Present Concerns/CC : “We don’t have any concerns. She just needs to get caught up on her shots.” Child Profile: Activities of Daily Living ( a g e a pp r o p r i at e) : The child can feed, bathe, and dress herself with some assistance. She helps around the house by picking up her toys at the end of the day. She typically goes to bed around 8:00 every night and sleeps for 12 hours. She takes 1-2 naps per day lasting 1-2 hours. S a f e ty Pr act i c e s : The mother reports that the patient is still in a car seat in the rear of the vehicle. 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 : Stays home with mother S p o r t s / ph y s ical ac t i vi t y : None D e v elo p m e n tal History : Child has achieved all development milestones thus far. S ex u al H i s t o r y (i f a p p r o p r i at e ) : Denies. HPI: The parent reports no concerns at this visit. This is a healthy 15 month-old child known to this practice. She is not up to date on all recommended immunizations. She is missing her 1 year vaccines, which will be administered today. Medications : None PMH: Allergies: None Chronic Illnesses/Major traumas: None Revised 5/9/18; 8/9/18; 10/29/18;10/22/19
Pediatric SOAP Note Hospitalizations/Surgeries: None Immunizations: Up to date Family Medical History: Father- Alive- no significant history Mother- Alive- Renal colic requiring surgery Social History 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 : The patient currently lives with her mother, father, and 3 older siblings. E d uc a t io nal le v e l (as appropriate) : Not currently in daycare of school. O cc up a t i on a l h i s t o r y (as appropriate) : N/A S u b s t an ce u s e / ab u s e (ETOH, tobacco, and marijuana): Mother denies alcohol and substance abuse. Firearms in home: Patient’s mother admits there are no firearms in the house.. S a f e ty s t a t u s : The home is protected without firearms. The patient is not left at home or unsupervised for any length of time.
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