Pediatrics
Share
Tweet
Cite
Click to rate this SOAPnote
[Total: 0 Average: 0]
approximately 85 views since a grouchy old Libertarian was peacefully absorbed into a spreadsheet.
.
[checkbox name="historian" value=" new patient|existing patient||parent present|sibling/another family member present|social services/group home/foster family present|chaperon/MA present during visit||interpretation provided by family member/SO|interpretation provided by MA|"][textarea cols=50 rows=3]
PMH/SPECIAL NEEDS/PARENTAL CONCERNS: [checkbox name="special" value="poor weight gain|allergies|anemia||none identified|"][textarea cols=50 rows=2]
INTERVAL HISTORY: [checkbox name="interval" value="sick contact|travel||ER/UC visit|illness|injury|hospitalization/surgery/procedure||diagnostic/laboratory studies|specialty consults||new/changed medications|ABX use||no changes since last visit|"][textarea cols=50 rows=2]
MEDICATIONS: [checkbox name="medications" value="Rx|OTC||taking as prescribed|not taking as prescribed||none reported|"][textarea cols=50 rows=2]
SCREENING: [checkbox name="screen" value="lead|TB||completed today & discussed with parent||consider formal referral|negative|deferred|"][textarea cols=50 rows=2]
GROWTH & DEVELOPMENT: [checkbox name="development" value="normal interval growth in height and weight|normal weight-for-length||expressing feelings|self-quieting||toilet training when ready|using correct terms for body parts|| providing praise|helping with fears and nightmares||age-appropriate development|some milestones not achieved|"][textarea cols=50 rows=2]
NUTRITION: discussed and/or handout provided, [checkbox name="nutrition" value="no forced foods|family meals|food variety: adequate daily intake of fruits, vegetables, calcium-containing foods, iron-containing foods|limiting juice/soda|milk less 16 oz||no concerns identified|"][textarea cols=50 rows=2]
DENTAL: discussed and/or handout provided, [checkbox name="dental" value="brushing teeth||no concerns identified|"][textarea cols=50 rows=2]
FAMILY: discussed and/or handout provided, [checkbox name="family" value="one-parent|two-parent|siblings|good sibling relationships||adequate living situation|attends daycare|stays at home||housing problems|custody issues|social services||no interval changes||no concerns identified|"][textarea cols=50 rows=2]
BEHAVIOR & SOCIAL: discussed and/or handout provided, [checkbox name="social" value="listening & responding to child|playing along other children|playing pretend games|imitating adults|providing adequate play time|limiting screen time||no concerns identified|"][textarea cols=50 rows=2]
LANGUAGE: discussed and/or handout provided, [checkbox name="language" value="modeling appropriate language|naming pictures|using 20 words|following 2-step command|putting two words together||no concerns identified|"][textarea cols=50 rows=2]
GROSS MOTOR: discussed and/or handout provided, [checkbox name="gross" value="kicking ball|walking up/down stairs one step at a time|throwing ball overhead|jumping up/down||no concerns identified|"][textarea cols=50 rows=2]
FINE MOTOR: discussed and/or handout provided, [checkbox name="fine" value="turning book pages one at a time|stacking blocks||no concerns identified|"][textarea cols=50 rows=2]
SAFETY: discussed and/or handout provided, [checkbox name="safety" value="choking prevention|home safety: window falls, burns, pets, guns||playground safety, supervision outside||car safety|water safety||smoking household|firearms in home||no concerns identified|"][textarea cols=50 rows=2]




.
ROS
10-point review of systems was performed and results were negative except for any positive results below
General:[textarea name="variable_5" default=" does not report fever, tired, changed behavior, fussy, or weight changes"]
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, or swollen neck glands"]
Chest/Respiratory:[textarea name="variable_8" default=" does not report shortness of breath, cough, phlegm, or wheezing"]
GI:[textarea name="variable_9" default=" does not report poor appetite, nausea, vomiting, abdominal pain, constipation, diarrhea, or 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, hip pain, knee pain, arthralgias, localized pain/swelling"]
Neurologic:[textarea name="variable_13" default=" does not report seizures, balance problems, weakness, or frequent 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"]



.
VACCINATION: [checkbox name="preventative" value="UTD|missing shots||administered today|deferred|declined|"][textarea cols=50 rows=2]
OFFICE DIAGNOSTICS: [checkbox name="office_diag" value="H&H|UA||normal|non-specific changes|abnormal||discussed with parent||none performed today|"][textarea cols=50 rows=2]
Appearance: [checkbox name="appearance" value="well-appearing|active|interactive||crying|consolable||NWOB|moist mucous membranes|age-appropriate behavior||inconsolable|irritable|uncooperative with exam|"][textarea cols=50 rows=2]
Skin: [checkbox name="skin" value="pink, no rashes|warm and well perfused|no bruising|"][textarea cols=50 rows=2]
Head/Face: [checkbox name="head" value="normocephalic and atraumatic|symmetrical face||scalp tenderness|plagiocephaly|swelling|"][textarea cols=50 rows=2]
Eyes: [checkbox name="eyes" value="red reflex present bilaterally|fixes and follows|normal ocular alignment||clear conjunctiva w/o exudates or hemorrhage||conjunctival injection|epiphora|conjunctival exudate|allergic shiners|dysconjugate gaze|"][textarea cols=50 rows=2]
ENT: [checkbox name="ent" value="normal ear canals & TMs, normal external nose|normal dentition for age|no oral lesions|op w/o swelling or exudates|"][textarea cols=50 rows=2]
Neck: [checkbox name="neck" value="symmetric with free painless ROM and no masses|supple|no LAD||anterior LAD|posterior LAD|"][textarea cols=50 rows=2]
Chest/Lungs: [checkbox name="lungs" value="unlabored respirations, symmetrical chest expansion|clear and equal breath sounds bilaterally||decreased bilaterally|wheezing|"][textarea cols=50 rows=2]
CV: [checkbox name="cv" value="regular rhythm|no murmurs||tachycardia|irregular heart rhythm|systolic murmur|"][textarea cols=50 rows=2]
Abdomen: [checkbox name="abd" value="no distension|normal active bowel sounds|soft non-tender|no obvious palpable masses||umbilical hernia|"][textarea cols=50 rows=2]
GU: [checkbox name="gu" value="declined exam||normal external genitalia|testes down bilaterally||uncircumcised|circumcised|"][textarea cols=50 rows=2]
MSK: [checkbox name="spine" value="no gross deformities|ambulates w/o limp or alteration in gait|normal spine|strength, tone, & bulk symmetrical|"][textarea cols=50 rows=2]
Neuro: [checkbox name="neuro" value="social|appropriate for age speech|"][textarea cols=50 rows=2]




A/P:
[checkbox name="ap" value="well child|"][textarea cols=50 rows=2]


.
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 - LABS: [checkbox name="order_lab" value="CBC|CMP|TSH|Lipids|A1C|lead|UA||none|"][textarea cols=50 rows=2]
ORDERS - REFERRALS: [checkbox name="order_refer" value="early intervention|WIC||none|"] [textarea cols=50 rows=2]
ORDERS - FORMS/RELEASE/CLEARANCE: [checkbox name="clearance" value="daycare physical||none"][textarea cols=50 rows=1]
INSTRUCTED ON: milestones, wellness, screening findings, exam findings, appropriate follow up [checkbox name="instruct" value="POC, reporting medication side effects immediately, indications for immediate direct evaluation and/or contacting emergency services|"][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=2]
FOLLOW UP: 6 months, sooner if concerns arise, [checkbox name="next" value="RTC 24 hours|RTC 2-3 days|RTC 1-2 weeks|RTC 3-4 weeks|"][textarea cols=50 rows=2]
PARENTAL BEHAVIOR: [checkbox name="behavior" value="calm|respectful||anxious|suspicious|irritable|frustrated||forceful|insisting on particular medication, test, referral, or accommodation||argumentative|hostile|raising voice|agitated||previous providers/staff criticisms|verbal threats||withdrawn|hypoverbal|"][textarea cols=50 rows=2]
BARRIERS TO CARE: [checkbox name="barriers" value="social/financial problems||incomplete history d/t parental lack of knowledge/affect|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|negative attitude to diagnostic impression & proposed tx||none identified|"][textarea cols=50 rows=1]
.

PMH/SPECIAL NEEDS/PARENTAL CONCERNS:
INTERVAL HISTORY:
MEDICATIONS:
SCREENING:
GROWTH & DEVELOPMENT:
NUTRITION: discussed and/or handout provided,
DENTAL: discussed and/or handout provided,
FAMILY: discussed and/or handout provided,
BEHAVIOR & SOCIAL: discussed and/or handout provided,
LANGUAGE: discussed and/or handout provided,
GROSS MOTOR: discussed and/or handout provided,
FINE MOTOR: discussed and/or handout provided,
SAFETY: discussed and/or handout provided,




.
ROS
10-point review of systems was performed and results were negative except for any positive results below
General:
HEENT:
Chest/Respiratory:
GI:
GU:
MSK:
Neurologic:
Psychiatric:
Dermatologic:
Hematologic/lymphatic:



.
VACCINATION:
OFFICE DIAGNOSTICS:
Appearance:
Skin:
Head/Face:
Eyes:
ENT:
Neck:
Chest/Lungs:
CV:
Abdomen:
GU:
MSK:
Neuro:




A/P:



.
ORDERS - RX:
ORDERS - LABS:
ORDERS - REFERRALS:
ORDERS - FORMS/RELEASE/CLEARANCE:
INSTRUCTED ON: milestones, wellness, screening findings, exam findings, appropriate follow up
PLAN OF CARE:
FOLLOW UP: 6 months, sooner if concerns arise,
PARENTAL BEHAVIOR:
BARRIERS TO CARE:

Result - Copy and paste this output:

Send Feedback for this SOAPnote

More SOAPnotes by this Author: