NR 509 Week 6 Pediatric SOAP Note, Summer 2021 complete solution.

NR 509 Week 6 Pediatric SOAP Note S: Subjective – Information the patient or patient representative told you O: Objective – Information gathered during the physical examination by inspection, palpation, auscultation, and palpation. If unable to assess a body system, write “Unable to assess”. Document pertinent positive and negative assessment findings. A: Assessment – Medical Diagnoses. Provide 3 differential diagnoses which may provide an etiology for the CC. The first diagnosis (presumptive diagnosis) is the diagnosis with the highest priority. Provide the ICD-10 code and pertinent findings to support each diagnosis. P: Plan – Address all 5 parts of the comprehensive treatment plan. If you do not wish to order an intervention for any part of the treatment plan, write “None at this time” but do not leave any heading blank. No intervention is self-evident. Provide a rationale and evidence-based in-text citation for each intervention.

SOAP Note Template

Initials: D.R. Age: 8 Gender: male

Height Weight BP HR RR Temp SPO2 Pain Allergies

4’2 90lbs

per

patient(

unable

to get a

standin

g

weight.

120/

76

100 28 37.2c 96% 3/10 Medication: Denies

Food: Denies

Environment: Denies

History of Present Illness (HPI)

Chief Complaint (CC) Cough CC is a BRIEF statement identifying

why the patient is here - in the patient’s

own words - for instance "headache",

NOT "bad headache for 3 days”.

Sometimes a patient has more than

one complaint. For example: If the

patient presents with cough and sore

throat, identify which is the CC and

which may be an associated symptom

Onset Cough started 5 days ago

Location throat

Duration Coughing every few minutes lasting 1-2min , for the past five days.

Characteristics Productive cough rated a 5 out of 10 with clear and thin sputum, cough

worsens at night. Associated symptoms of sore throat and earache,(gargly and

watery associated with sore throat)

Aggravating Factors Worse at night. Reports cough stays the same no matter what I do. (cough at

night think CHF, GERD, Asthma…)

Relieving Factors Cough medicine “helped a little”

Treatment resting

Current Medications: Include dosage, frequency, length of time used and reason for use; also include OTC or homeopathic products.

Medication

(Rx, OTC, or Homeopathic) Dosage Frequency Length of Time

Used Reason for Use

Gummy multivitamin 2-4 gummies daily Unable to

answer my

question when

asked.

“to stay healthy”

Cough medicine “ a spoonful” One time “Once this AM” Cough

S: Subjective

Information the patient or patient representative told you

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Past Medical History (PMHx) – Includes but not limited to immunization status (note date of last tetanus for all adults), past major illnesses,

hospitalizations, and surgeries. Depending on the CC, more info may be needed.

-Reports frequent colds and Rhinorrhea. Reports no fever last few times mother checked temperature. Hx of frequent earaches at 2 yrs old.

-Pneumonia last year at 7 years old, missed school for 2 weeks, treated at an urgent care with unknown antibiotics (can’t recall the name).

-Hearing checked 1 month ago at school: reports it was normal.

-Last dental visit 2 months ago: reports no cavities.

-Denies any previous surgeries. Stated has tonsils still and no ear surgeries. Denies prior hospitalizations.

According to patient chart immunizations up to date at this time. No influenza vaccine, last 12 months.

Social History (Soc Hx) - Includes but not limited to occupation and major hobbies, family status, tobacco and alcohol use, and any other pertinent

data. Include health promotion such as use seat belts all the time or working smoke detectors in the house.

Student: 3rd grader. Only child.Exposed to second hand smoke by father who smokes inside the house sometimes.

Lives with Abeula (maternal grandmother), mother,Papi (father), and Abuelo (grandfather). Mother is a stenographer. Father is a security officer for

court. States: “ I always feel safe at home. I have a good family!”. No pets in household. Reports drinks 7-8 glasses of water/ day. Goes to gym

class everyday at school for exercise and plays at the park after school or sometimes on weekends. Hobbies: play video games, read, try to write

stories with best friend Tony. Denies using tobacco or alcohol use.

Family History (Fam Hx) - Includes but not limited to illnesses with possible genetic predisposition, contagious or chronic illnesses. Reason for

death of any deceased first degree relatives should be included. Include parents, grandparents, siblings, and children. Include grandchildren if

pertinent.

Lives with grandparents and parents.

Mother: DM2, HTN,hypercholesterolemia, obesity.

Father: Current Smoker (couple of times a week, smokes inside) history of childhood asthma. HTN , hypercholesterolemia.

Maternal Grandma:DM type 2, HTN

Maternal Grandpa: doesn’t see a doctor

Paternal grandma: died in a car accident (52yrs. Old)

Paternal grandpa: unknown (estranged)

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