Musculoskeletal ROM intact no difficulties No signs of congenital hip dysplasia

Musculoskeletal rom intact no difficulties no signs

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Musculoskeletal: ROM intact, no difficulties. No signs of congenital hip dysplasia. Ortolani and Barlow maneuvers are negative. Revised 5/9/18; 8/9/18; 10/29/18;10/22/19
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Pediatric SOAP Note Neurological: AAOx4. Calm. Cooperative. Spine midline, no difficulties with ROM. Posture, tone and activity level are within normal limits for age. Behavioral/Psychiatric: Alert. Pediatric/Adolescent Assessment Tools: HEADSS- H- Home- Lives at home with mother, father and siblings. Never home alone. E-Education- Stays home with mother. A-Activities- Eat, Sleep, Pee, Poop and Grow. D-Drugs- No illicit drug usage S-Suicidality- Happy, calm. S-Sex- No sexual contact. Present Developmental: Child developmentally appropriate. Lab and/or Diagnostic Tests: None Immunizations: None DIAGNOSIS Instructions: Final/Primary Diagnosis (es): Z00.111 Routine Child Health Exam Classified as any well child exam for a child 8 to 28 days old. Q38.1 Ankyloglossia: Congenital malformation of the tongue, mouth or throat (Tongue tie) P92.9- Feeding problem of newborn, unspecified: Poor weight gain from discharge weight PLAN: Medication: none Pharmacological treatments: None Non-Pharmacological treatments: Discussed findings with parent. Discussed nutrition, sleep, safety, development, feeding schedule, feed on demand, may continue to supplement with formula if needed. Ensure adequate wet and dirty diapers, Return in 1 week for weight recheck. Discussed normalcy of Revised 5/9/18; 8/9/18; 10/29/18;10/22/19
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Pediatric SOAP Note bowel movements with alternating breastmilk and formula. Will recheck next week. Follow up: In 1 week for weight recheck Vaccinations: None (Stead,2019). (American Association of Pediatrics, 2017). Self-Evaluation of Interaction with patient/family during clinic visit: This well child check went very well. The mother was responsive and interactive with me. References: “Clinical Practice.” Clinical Practice , 2017, - practice/Pages/default.aspx. Revised 5/9/18; 8/9/18; 10/29/18;10/22/19
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Pediatric SOAP Note Revised 5/9/18; 8/9/18; 10/29/18;10/22/19
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Pediatric SOAP Note Revised 5/9/18; 8/9/18; 10/29/18;10/22/19
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