Adolescent Routine Annual Full SOAP

CC: [text name="variable_1" default="annual wellness"]
* HPI: [textarea name="variable_2" default="Patient XX is a -age- -ethnicity- male/female who is here for a routine annual check-up. Patient is present here today with his/her mom / dad/ grandma/ grandpa / aunt / sibling / who has written consent from guardian."]
[textarea name="variable_3" default="Patient appears relaxed, makes good eye contact and speaks clearly and easily"]
* Annual: [textarea name="variable_45" default="Patient says he/she is doing good. He/She is currently -school grade-. Grades in school are ----. He/She plays -sport- for her school. Denies drug or alcohol use. Is not currently employed. Denies being sexually active / Admits to being sexually active and would like to discuss birth control options."]
Diet: [textarea name="variable_4" default="patient says his/her diet is “okay” and he/she does try to eat healthy"]
Exercise: [textarea name="variable_5" default="patient says he does not routinely exercise but does not have any issues participating in school activities and P.E."]
Allergies: [text name="variable_6" default="NKDA"]
Medical History: [text name="variable_7" default="None. /Asthma"]
Past Hospitalizations: [text name="variable_8" default="None."]* ROS
-Skin: [textarea name="variable_9" default="denies rashes or lesions; denies new nevi"]
-HEENT: Head: [textarea name="variable_10" default="denies migraines/headaches; Eyes: no corrective lenses or glasses. Ears: denies difficulty with hearing; denies tinnitus or vertigo. Nose/Sinuses: denies nasal congestion, sinus pressure/pain, and epistaxis. Teeth: denies issues"]
-Neck/Throat: [textarea name="variable_11" default="denies pain, lumps, or lymphadenopathy"]
-Cardiovascular: [textarea name="variable_12" default="denies chest pain, palpitations, or tachycardia."]
-Respiratory: [textarea name="variable_13" default="denies cough, congestion, wheezing, or dyspnea"]
-Gastrointestinal: [textarea name="variable_14" default="denies abdominal discomfort, heartburn, reflux; reports regular voids and stools w/no issues"]
-Genitourinary: [textarea name="variable_15" default="denies any problems. ****LMP was / denies severe pain w/menses"]
-Musculoskeletal: [textarea name="variable_16" default="denies joint stiffness, joint pain or swelling"]
-Integumentary/Breast: [textarea name="variable_17" default="denies rash, pain, or masses"]
-Neurological: [textarea name="variable_18" default="denies seizures, sensory loss, headaches, migraines, or lethargy"]
-Hematologic/Lymphatic: [textarea name="variable_19" default="denies bruising, bleeding, and lymphadenopathy generally"]
-Endocrine: [textarea name="variable_20" default="no reported hair loss; skin is warm and dry; no night sweats reported"]
-Psychiatric: [textarea name="variable_21" default="denies anxiety and depression."]Objective
* Vitals: HR [text name="variable_22" default=" "], RR[text name="variable_23" default=" "], Wt [text name="variable_24" default=" lb."], Ht [text name="variable_25" default=" in."], BMI [text name="variable_26" default=" "], BP [text name="variable_27" default=" "], Spo2 [text name="variable_28" default=" %"]* Physical Exam
GENERAL: [textarea name="variable_29" default="The patient is well developed, well nourished, alert and cooperative and appears to be in no acute distress. Vital signs as noted."]
EYES: [textarea name="variable_30" default="Normal eye and funduscopic exam."]
VISION SCREEN: [textarea name="variable_31" default="right eye 20/20, left eye 20/20"]
EAR, NOSE, AND THROAT: [textarea name="variable_32" default="Ear canals and tympanic membranes are clear, and hearing is grossly intact. Nose revels no obstruction or discharge. Oropharynx reveals no inflammation, swelling, exudate, or lesion. Lips, teeth, and gums are in good general condition."]
NECK: [textarea name="variable_33" default="No thyromegaly."]
LYMPH: [textarea name="variable_34" default="No adenopathy."]
RESPIRATORY: [textarea name="variable_35" default="Lungs are clear to auscultation and percussion without rales, rhonchi, wheezing, rub diminished breath sounds, or labored breathing."]
HEART: [textarea name="variable_36" default="Regular rhythm with no significant murmurs, rubs, gallops, or clicks."]
ABDOMEN: [textarea name="variable_37" default="Abdomen is soft, nontender without masses, hepatosplenomegaly, or abnormal pulsation. There is no guarding or tenderness."]
GENITALIA: [textarea name="variable_38" default="Deferred-denies any issues."]
MUSCULOSKELETAL: [textarea name="variable_39" default="Examination shows no significant weakness or deformity of the musculoskeletal system. Can perform duck walk and heel-toe walk."]
SKIN: [textarea name="variable_40" default="Normal, without rash or lesion."]*Labs: [text name="variable_41" default="None."]
*Diagnostics: [text name="variable_42" default="None."]PREVENTATIVE HEALTH
Immunizations: [text name="variable_42" default="UTD / Provided vaccine today: INFLUENZA/ MENB/ MCV4 / TDAP"]ASSESSMENT/PLAN
[textarea name="variable_43" default="Z00.129 - ENCNTR FOR ROUTINE CHILD HEALTH EXAM W/O ABNORMAL FINDINGS * Annual examination completed today. Preventative care updated and reviewed. * Educated patient on dietary habits and on increasing fresh vegetables into the diet and limiting soda intake. Encouraged regular exercise and participation in school activities."]
[textarea name="variable_48" default="Z23 - ENCOUNTER FOR IMMUNIZATION * Vaccination schedule reviewed. *****Patient receiving vaccine / UTD, no vaccines administered today."]
Follow-up: [text name="variable_46" default="routine annual"]
* HPI:

* Annual:
Medical History:
Past Hospitalizations: * ROS
-HEENT: Head:
-Psychiatric: Objective
* Vitals: HR , RR, Wt , Ht , BMI , BP , Spo2 * Physical Exam
SKIN: *Labs:
Immunizations: ASSESSMENT/PLAN


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