1NSG_6435_Week_1_SOAP.docx - Pediatric SOAP Note Date Age\/DOB\/Place of Birth 3yrs\/Tallapoosa GA Name KC Sex Female Historian Mother Present Concerns\/CC

1NSG_6435_Week_1_SOAP.docx - Pediatric SOAP Note Date...

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N a m e: KC D a te: 7/17/20 S e x: Female A g e / D OB/ P la ce o f Bi rt h : 3yrs/6-23-17/Tallapoosa, GA His t o r ian : Mother Pre s e n t C on cer ns/ CC : “3 year visit” C hil d Pr o f il e: Pt is a healthy looking 3year old Caucasian female. The mother states her overall health is good, she is very active and playful. Mother states the child has no past medical history or developmental delays. She has a good vocabulary. Mom states patient has had no serious injuries. She states the patient is a happy child and eats a nutritional diet and spends her time playing with her older sister. She sleeps in her toddler bed at night for a minimum of 8 hours and takes at least one hour nap mid afternoon . H P I : 3-year old child brought in by her mother comes to clinic for her 3 year well child visit. The patient has no previous medical history. The child is alert and sitting with her mom. Pt appears well groomed, clean and is well behaved . M e di c a t i ons : None Allergies: None reported Medication Intolerances: None Hospitalizations/Surgeries: None Immunizations: Up to date Family History Mother, 28, Overweight, otherwise healthy Father, 29, HTN- well controlled with medication. Sister, 6, Healthy Social History Pt lives with her Mother, Father and older sister. Mother reports no one smokes around child. Mother and Father work full time, while the pt and her sister stay home with a trusted babysitter 4 days a week. Mom denies alcohol, tobacco or substance use by her or the father. P ediat r ic SOAP N o te
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General Mother states the child is a happy active 3 year old. Mom denies any recent sickness, weight changes, fever or problems with sleeping.
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