Name:
Date:
Sex:
Age/DOB/Place of Birth:
SUBJECTIVE
Historian:
Present Concerns/CC:
Reason given by the patient for seeking medical care “in quotes”
Child Profile: (Sexual History (If appropriate); ADLs (age appropriate); Safety Practices; Changes in daycare/school/after-school care; Sports/physical activity; Developmental Hx)
HPI: (must include all components)
Medications: (List with reason for med )
PMH:
Allergies:
Medication Intolerances: Chronic Illnesses/Major traumas: Hospitalizations/Surgeries: Immunizations:
Family History ( Please identify all immediate family)
Social History Education level, occupational history, current living situation/partner/marital status, substance use/abuse, ETOH, tobacco, and marijuana. Safety status
ROS
General
Cardiovascular
Skin
Respiratory
Pediatric SOAP Note
Eyes
Gastrointestinal
Ears
Genitourinary/Gynecological
Nose/Mouth/Throat
Musculoskeletal
Breast
Neurological
Heme/Lymph/Endo
Psychiatric
OBJECTIVE (plot height/weight/head circumference along with noting percentiles) Attach growth chart
Weight
Temp
BP
Height
Pulse
Resp
General Appearance and parent‐child interaction
Skin
HEENT
Cardiovascular
Respiratory
Gastrointestinal
Breast
Genitourinary
Musculoskeletal
Neurological
Psychiatric
In-house Lab Tests – document tests (results or pending)
Pediatric/Adolescent Assessment Tools (Ages & Stages, etc) with results and rationale
For adolescents (HEADSSSVG Assessment)
Diagnosis
· Include at least three differential diagnoses with ICD-10 codes. (Includes Primary dx and 2 differentials)
· Document Evidence based Rationale for ROS and each differential with pertinent positives and negatives
· Primary diagnosis
· Is #1 on list of differentials
· Evidence for primary diagnosis should be supported in the Subjective and Objective exams.
PLAN including education
· Plan: Treatment plan should be for the Primary Diagnosis and based on EB literature.
· Include EB rationale for all aspects of your treatment
plan:
· Vaccines administered this visit
· Vaccine administration forms given
· Medication-amounts and mg/kg for medications
· Laboratory tests ordered
· Diagnostic tests ordered
· Patient education including preventive care and anticipatory guidance
· Non-medication treatments
· Follow-up appointment with detailed plan of f/u
*ALL references must be Evidence Based (EB)
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