y (as appropriate) : None S u b s t an ce u s e / ab u s e (ETOH, tobacco, and marijuana): None Firearms in home: None S a f e ty s t a t u s : Patient’s mother stated she constantly has to take things out of patient’s mouth Revised 5/9/18; 8/9/18; 10/29/18
Pediatric SOAP Note REVIEW OF SYSTEMS (Do not omit any body system & remember this is a child not an adult) General: Mom denies weight changes, fever, chills or night sweats, states patient has high energy level Cardiovascular: Mom denies cardiac problems, no evidence of edema or difficulty breathing Skin: Denies bruising or wounds, just a few minor scrapes from being a boy and running around Respiratory: Mom states patient coughs when he runs around to much or gets hot, denies wheezing, hemoptysis, dyspnea, pneumonia or TB Head: Per mom, normal for age and body Breast: No lumps, bumps or changes Eyes: No corrective lenses, blurred vision or visual changes Gastrointestinal: no abdominal pain, N/V/D, denies constipation, or eating disorders, normal bowel movements daily Ears: Bilateral tubes in ears placed in 11/2016 Musculoskeletal: per mom no problems walking, no history of fractures or surgeries Nose/Mouth/Throat: Mom states patient does have sinus drainage at times, with sneezing mainly in the mornings when he wakes up, normal teeth pattern, no broken teeth or cavities Neurological: Per mom no history of seizures or weakness, walks without difficulty, no problems with memory or passing out. Genitourinary/Gynecological: Per mom, no urinary complaints, normal penis, voiding without difficulty, no c/o pain or burning upon urination Heme/Lymph/Endo: Minor scrapes and bruises, no bleeding problems Developmental Problems: Speech delay, does not articulate words and does not make complete sentences Behavioral Status/Psychiatric: Gets frustrated when unable to articulate needs and wants OBJECTIVE ( Attach growth chart with height/weight/head circumference plotted & noting percentiles; attach these forms at the end of your SOAP note; include pertinent positives & negatives ) Weight: (include lb, kg; BMI) 45lbs, BMI-19.77 Temp: 97.4 BP: 88/60 Height: (inches, cm, or feet) 3’4” Pulse: 80 Respirations: 12 General Appearance & parent ‐ child interaction: (also include orientation) Healthy appearing 4-year-old sitting on the exam table, talking and playing with his mom and siblings. Makes eye contact, well groomed. Skin: (includes nails, turgor, temp, capillary refill) Skin clear, no bruises or open wounds, good capillary refill, normal skin turgor, finger nails short and clean. Revised 5/9/18; 8/9/18; 10/29/18
Pediatric SOAP Note Head: (include facial appearance & symmetry, shape, hair & texture, scalp condition, fontanels & suture lines [-20months old]) Head: round and symmetrical, atraumatic without lesions, hair evenly distributed, scalp non-tender, no masses rashes, lumps, rashes or scars.
- Summer '17
- SOAP Note, speech delay, language delay