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Father: 40-year- white male with no known health problems.Social 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. This is their first child. Educationallevel (as appropriate):NAOccupationalhistory (as appropriate):NASubstanceuse/abuse(ETOH, tobacco, and marijuana): NAFirearms in home: No guns in home. Safetystatus:Parents are using car seat, have not had infant around large crowds, infant sleeps on back in crib, does practice safety as infant can roll over now, smoke and carbon monoxide detector in home, child safety locks on cabinetsREVIEW OF SYSTEMS(Do not omit any body system & remember this is a child not an adult) General:Mother denies fever and fatigue, decreased appetite. Denies difficulty sleeping, chills, malaise, night sweats, unexplained weight loss or weight gain.Cardiovascular:Mother denies chest pain, palpitations, PND, orthopnea, edemaSkin:Mother denies delayed healing, rashes, bruising, bleeding or skin discolorations, any changes in lesions or molesRespiratory:Mother denies cough, wheezing, hemoptysis, dyspnea, pneumonia hx, TBHead:Mother denies headaches, concussions, unusual head shapeBreast:Mother denies lumps, bumps or changesEyes:Mother denies corrective lenses, blurring, visual changes of any kindGastrointestinal:Mother denies abdominal pain, N/V/D. Denies constipation, hepatitis, hemorrhoids, eating disorders, ulcers, black tarry stoolsEars:Mother denies ear pain, hearing loss, ringing in ears, dischargeMusculoskeletal:Mother denies back pain, joint swelling, stiffness or pain, fracture hx, osteoporosisNose/Mouth/Throat:Mother denies sinus problems, sore throat, dysphagia, nose bleeds or discharge, dental disease, hoarsenessNeurological:Mother denies syncope, seizures, transient paralysis, weakness,paresthesia, black out spellsGenitourinary/Gynecological:Mother denies urgency, frequency burning, change in colorof urine.Heme/Lymph/Endo:Mother denies depression, anxiety, sleeping difficulties, suicidal ideation/attempts, previous dxRevised 5/9/18; 8/9/18; 10/29/18
Pediatric SOAP NoteDevelopmental Problems: Mother denies any developmental problems Behavioral Status/Psychiatric:Mother denies HIV status, bruising, blood transfusion hx, night sweats, swollen glands, increase thirst, increase hunger, cold or heat intoleranceRevised 5/9/18; 8/9/18; 10/29/18
Pediatric SOAP NoteOBJECTIVE(Attach growth chartwith height/weight/head circumference plotted & noting percentiles; attach these forms at the end ofyour SOAP note; include pertinent positives & negatives)Weight: 17 lbs Temp: 98.1BP: not measuredHeight: 27 in Pulse 120Respirations: 38