Pediatrics
Share
Tweet
Cite
Click to rate this SOAPnote
[Total: 0 Average: 0]
approximately 403 views since things began happening sequentially.
.
[checkbox name="historian" value="new patient|existing patient||history provided by patient|history provided by parent/family member||family member present during visit|chaperon/MA present during visit||interpretation provided by family member/SO|interpretation provided by MA|"][textarea cols=50 rows=3]
CC: [checkbox name="cc" value="cold|fever|runny nose|nasal congestion|earache/pulling on ear(s)|sore throat|cough|stridor|wheezing|rash||poor appetite|abd pain|diarrhea|nausea|dysuria|"][textarea cols=50 rows=3]
RECENT HISTORY: [checkbox name="recent" value="day care/school attendance|sick contact|consumption of food outside home|travel|ER/UC visit|hospitalization/surgery/procedure|diagnostic/laboratory studies|specialty consults|new/changed medications|ABX use||non-contributory|"][textarea cols=50 rows=3]
MEDICATIONS: [checkbox name="medications" value="Rx|OTC||reports no side effects|reports side effects||effective|partially effective|not effective||taking as prescribed|not taking as prescribed|did not try||none reported|"][textarea cols=50 rows=2]
IMMUNIZATION: [checkbox name="immunization" value="UTD|missing shots|today|flu|deferred|"][textarea cols=50 rows=2]
PMH: [checkbox name="pmh" value="|frequent infections|frequent ABX use|asthma|allergies|eczema||non-contributory|"][textarea cols=50 rows=3]
[checkbox memo="SCREENS COMPLETED" name="screen" value=""][conditional field="screen" condition="(screen).is('')"][checkbox name="screen" value="depression||none"][textarea cols=50 rows=3][/conditional]


.
HPI: [checkbox name="hpi" value="new problem|chronic condition|acute exacerbation of chronic condition||started today|started yesterday|started several days ago|started more than 1 week ago|started months ago|started years ago|unsure||sx still present|sx increasing in severity|sx persisting|occasional sx|sx decreasing|sx resolved||affected by medication|affected by position/movement||as in cc|"][textarea cols=50 rows=3]


.
REVIEW OF SYSTEMS: negative except as stated in HPI
General:[textarea name="variable_5" default=" does not report fever, tired, changed behavior, fussy"]
HEENT:[textarea name="variable_6" default=" does not report headache, scalp swelling, facial swelling, eye redness/discharge, itching, periorbital swelling, earache, ear discharge, wax, nasal congestion, rhinorrhea, bleeding, mouth sores, infection, sore throat, hoarseness, swollen neck glands"]
Chest/Respiratory:[textarea name="variable_8" default=" does not report shortness of breath, cough, phlegm, wheezing, or chest wall pain with breathing"]
GI:[textarea name="variable_9" default=" does not report poor appetite, nausea, vomiting, abdominal pain, constipation, diarrhea, rectal itching/bleeding"]
GU:[textarea name="variable_10" default=" does not report dysuria, hematuria, frequency, urine odor, discharge, or skin lesion/rash"]
MSK:[textarea name="variable_11" default=" does not report limping, myalgias, arthralgias, localized muscle/soft tissues pain/swelling, or joint pain/swelling"]
Neurologic:[textarea name="variable_13" default=" does not report dizziness, seizures, balance problems, weakness, or falls"]
Psychiatric:[textarea name="variable_14" default=" does not report anxiety, mood swings, behavioral issues, or sleep problems"]
Dermatologic:[textarea name="variable_12" default=" does not report rashes, redness, pruritus, swelling, bruising, or wounds"]
Hematologic/lymphatic:[textarea name="variable_16" default=" does not report abnormal bleeding/bruising"]



.
OFFICE DIAGNOSTICS: [checkbox name="office_diag" value="normal|non-specific changes|no acute findings||discussed with patient/SO|official report to follow||none performed today|"][textarea cols=50 rows=2]
DIAGNOSTIC & LABORATORY RESULTS: [checkbox name="new_labs" value="normal|non-specific changes|no acute findings||discussed with patient/SO||no new results|"][textarea cols=50 rows=3]
Appearance: [checkbox name="appearance" value="well-appearing|active|interactive|non-toxic|strong suck||crying|consolable||NWOB|moist mucous membranes|age-appropriate behavior||ill-appearing|inconsolable|irritable|diaphoretic|short of breath|uncooperative with exam|"][textarea cols=50 rows=2]
Head: [checkbox name="head" value="normocephalic, atraumatic||normal anterior fontanel||scalp tenderness|plagiocephaly|swelling|"][textarea cols=50 rows=2]
Face: [checkbox name="face" value="symmetrical|no evidence of trauma|no obvious cranial nerve deficits||rash|swelling|ecchymosis|"][textarea cols=50 rows=2]
Eyes: [checkbox name="eyes" value="clear conjunctiva w/o exudates or hemorrhage, anicteric sclera, EOM intact, painless, without nystagmus, visual acuity grossly intact|PERL|corneas clear||allergic shines|dennie lines|periorbital swelling|conjunctival injection|epiphora|conjunctival exudate|palpebral edema|palpebral exudates|dysconjugate gaze|"][textarea cols=50 rows=2]
Ears: [checkbox name="ears" value="symmetrical & intact auricles bilaterally, hearing to conversation intact|no tragal tenderness|clear canals without erythema or D/C|no FB visible in canals|TMs normal in appearance|no mastoid tenderness||tragal tenderness|swelling of external auditory canal|debris in canal|cerumen in canal|dried up blood in canal|TM obscured by cerumen|TM red|pus behind TM|fluid behind TM|TM bulging|TM perforated|TM retracted|tube in TM|mastoid tenderness|"][textarea cols=50 rows=2]
Nose: [checkbox name="nose" value="nares patent bilaterally|no facial tenderness|mucosa pink & moist||allergic salute|maxillary tenderness|frontal tenderness|deviated septum||swollen & boggy mucosa|mucosal ulceration|mucosal congestion||clear discharge|yellow discharge|crusty discharge|bloody discharge|active septal hemorrhage|clotted blood|"][textarea cols=50 rows=2]
Mouth: [checkbox name="mouth" value="tongue normal in appearance w/o lesions|moist oral mucosa without lesions|normal dentition for age||single oral ulcer|multiple oral ulcers|gum swelling|tooth caries|"][textarea cols=50 rows=2]
Throat: [checkbox name="throat" value="normal voice, patent pharynx w/o swelling or exudates|uvula midline|clear pharynx w/o exudates||pharyngeal erythema w/o exudates|hoarseness|vesicles on soft palate|petechiae on soft palate||pharyngeal crowding|tonsilar enlargement|tonsilar erythema|tonsilar exudates|tonsilar crypts|tonsilar pustules|"][textarea cols=50 rows=2]
Neck: [checkbox name="neck" value="symmetric with free painless ROM|no LAD||anterior LAD|posterior LAD|nuchal tenderness|"][textarea cols=50 rows=2]
Lungs: [checkbox name="lungs" value="normal work of breathing, symmetrical chest expansion|clear and equal breath sounds bilaterally||SOB|stridor|intercostal retractions|wheezing|crackles|barky cough|dry cough|wet cough|"][textarea cols=50 rows=2]
CV: [checkbox name="cv" value="chest wall atraumatic|regular rhythm, no murmurs|pedal skin warm with good & equal pulses||tachycardia|systolic murmur||sternal tenderness|breast mass|breast tenderness|skin dimpling/retraction|"][textarea cols=50 rows=2]
Abdomen: [checkbox name="abd" value="normal visual inspection, no distension|normal active bowel sounds throughout|soft non-tender|non-disturbed with abdomen palpation|no obvious palpable masses or hepatosplenomegaly|heel-drop negative||diffuse tenderness over entire abdomen w/o RRG|direct non-rebound tenderness|umbilical hernia||hypoactive bowel sounds|hyperactive bowel sounds|"][textarea cols=50 rows=2]
GU: [checkbox name="gu" value="no CVAT bilaterally|no suprapubic tenderness||normal external genitalia|circumcised|uncircumcised|smooth non-tender testes|+cremasteric reflexes bil|no skin lesions||testicular tenderness|vesicles||deferred|"][textarea cols=50 rows=2]
Back: [checkbox name="spine" value="no gross deformities, normal curvature & ROM||scoliosis|"][textarea cols=50 rows=2]
Extremities:
[checkbox name="extremity" value="atraumatic w/o swelling or deformity|free and painless ROM in upper extremities|free and painless ROM in lower extremities|strength and tone symmetrical & grossly intact||DROM|tenderness|swelling|"][textarea cols=50 rows=2]
Neuro: [checkbox name="neuro" value="alert, balance & coordination grossly intact|full weight bearing|normal vocalization|CN grossly intact|no gross motor deficits|sensation symmetrical & grossly intact||reflexes normoactive||antalgic gait|"][textarea cols=50 rows=2]
Psych: [checkbox name="psych" value="appropriate to age/situation|normal concentration and attention|good eye contact||anxious|irritable|"][textarea cols=50 rows=2]
Skin: [checkbox name="skin" value="grossly intact, no rashes|no bruises|normal turgor||poor turgor|dry|sweaty||erythema|induration|firm|soft|deep|mobile|fluctuant|painful||abrasion|excoriation|fissure|laceration|ulceration|ecchymosis|swelling|burn||generalized rash|acral rash|symmetrical|unilateral|linear|annular|arcuate|serpiginous|red scaly|red non-scaly|macular|papular|maculopapular|follicular|urticarial|targetoid|vesicular|pustular||purpuric|non-blanching|sharply-demarcated borders|indistinct borders|"][textarea cols=50 rows=2]


A/P: [textarea cols=50 rows=5]

.
ORDERS - RX: [checkbox name="order_RX" value="OTC||electronic|paper|given to MA to be transmitted to pharmacy||none|"][textarea cols=50 rows=1]
ORDERS - VACCINATION: [checkbox name="preventative" value="UTD|deferred|flu||deferred|"][textarea cols=50 rows=2]
ORDERS - LABS: [checkbox name="order_lab" value="CBC|CMP|TSH|A1C|Lipids||none|"][textarea cols=50 rows=2]
ORDERS - IMAGING: [checkbox name="order_imaging" value="X-ray|US||none|"][textarea cols=50 rows=2]
ORDERS - OUTSIDE REFERRALS: [checkbox name="order_refer" value="none|"] [textarea cols=50 rows=2]
ORDERS - FORMS/RELEASE/CLEARANCE: [checkbox name="clearance" value="excuse from school||cleared for sports participation|cleared for school return|without restrictions|with restrictions||none|"][textarea cols=70 rows=1]
ORDERS - STAFF INSTRUCTIONS: [checkbox name="MA" value="dsg change/wound care as instructed|obtain hospital/ER discharge report|obtain specialty report|obtain imaging report|obtain laboratory report||schedule f/u|"][textarea cols=50 rows=2]
REVIEWED/DISCUSSED: [checkbox name="reviewed" value="MA notes|med list|previous visits|laboratory/diagnostic studies|advised that negative/'normal' results do not rule out pathology|specialty reports|hospital discharge|"][textarea cols=50 rows=2]
INSTRUCTED ON: exam findings, POC, risks of/benefits of/alternatives to proposed POC, compliance with treatment regimen, reporting medication side effects immediately, appropriate follow up specific to condition, indications for immediate direct evaluation and/or contacting emergency services
[checkbox name="instructions" value="OTC medicines and comfort measures for symptom control|adequate hydration/water intake||weight reduction/exercise|carbs restriction||age-appropriate screening and immunization|"][textarea cols=50 rows=1]
PLAN OF CARE: [checkbox name="discussed" value="verbalized understanding of & agreement with POC|did not agree with my POC – will seek second opinion/further care elsewhere|"][textarea cols=50 rows=3]
DISCHARGE CONDITION/SAFETY: [checkbox name="discharge" value="improved|stable|unchanged||no safety concerns at this time||safety concerns d/t parental knowledge/mood|safety concerns d/t custody issues|"][textarea cols=50 rows=1]
FOLLOW UP: as discussed, sooner if condition worsens or new symptoms arise, contact 911/ER if significant increase in s/sx or appearance of new/danger s/sx, [checkbox name="next" value="RTC 24 hours|RTC 2-3 days|RTC 1-2 weeks|RTC 3-4 weeks|RTC 30 days|RTC 90 days||medication review|f/u acute episode|f/u labs|f/u imaging|f/u referral|"][textarea cols=50 rows=2]
DISPOSITION: [checkbox name="disposition" value="home||referred to ER for immediate treatment via 911|referred to ER for immediate treatment via private transport||declined emergency transfer|left clinic before being discharged|asked to leave clinic|"][textarea cols=50 rows=1]
PARENTAL BEHAVIOR: [checkbox name="behavior" value="calm|pleasant|respectful||anxious|fearful|suspicious|irritable|frustratedcrying||forceful|insisting on particular medication, test, referral, or accommodation|argumentative||hostile|raising voice|agitated|cursing, swearing||previous providers/staff criticisms|verbal threats|sexual remarks|racist remarks||flat affect|bradykinetic|indifferent|appears to be responding to internal psychotic process|"][textarea cols=50 rows=2]
BARRIERS TO CARE: [checkbox name="barriers" value="incomplete history d/t parental anxiety/behavior|incomplete history d/t parental lack of knowledge|incomplete history d/t language barrier||vague shifting complaints|history not supported by objective findings|supporting documentation unavailable||poor cooperation with exam|poor compliance with POC|intolerance of/therapeutic failure on multiple meds||lack of motivation on parent's part|negative parental attitude to diagnostic impression & proposed tx||none noted at this time|"][textarea cols=50 rows=1]
.

CC:
RECENT HISTORY:
MEDICATIONS:
IMMUNIZATION:
PMH:
SCREENS COMPLETED


.
HPI:


.
REVIEW OF SYSTEMS: negative except as stated in HPI
General:
HEENT:
Chest/Respiratory:
GI:
GU:
MSK:
Neurologic:
Psychiatric:
Dermatologic:
Hematologic/lymphatic:



.
OFFICE DIAGNOSTICS:
DIAGNOSTIC & LABORATORY RESULTS:
Appearance:
Head:
Face:
Eyes:
Ears:
Nose:
Mouth:
Throat:
Neck:
Lungs:
CV:
Abdomen:
GU:
Back:
Extremities:

Neuro:
Psych:
Skin:


A/P:

.
ORDERS - RX:
ORDERS - VACCINATION:
ORDERS - LABS:
ORDERS - IMAGING:
ORDERS - OUTSIDE REFERRALS:
ORDERS - FORMS/RELEASE/CLEARANCE:
ORDERS - STAFF INSTRUCTIONS:
REVIEWED/DISCUSSED:
INSTRUCTED ON: exam findings, POC, risks of/benefits of/alternatives to proposed POC, compliance with treatment regimen, reporting medication side effects immediately, appropriate follow up specific to condition, indications for immediate direct evaluation and/or contacting emergency services

PLAN OF CARE:
DISCHARGE CONDITION/SAFETY:
FOLLOW UP: as discussed, sooner if condition worsens or new symptoms arise, contact 911/ER if significant increase in s/sx or appearance of new/danger s/sx,
DISPOSITION:
PARENTAL BEHAVIOR:
BARRIERS TO CARE:

Result - Copy and paste this output:

Send Feedback for this SOAPnote

More SOAPnotes by this Author: