We Write Custom Academic Papers

100% Original, Plagiarism Free, Customized to your instructions!

Pediatric SOAP Note

Pediatric SOAP Note

Pediatric SOAP Note

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

Pediatric SOAP Note

*ALL references must be Evidence Based (EB)

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

Our Service Charter
________________________________________
1. Professional & Expert Writers: Nursing Experts .org only hires the best. Our writers are specially selected and recruited, after which they undergo further training to perfect their skills for specialization purposes. Moreover, our writers are holders of masters and Ph.D. degrees. They have impressive academic records, besides being native English speakers.
2. Top Quality Papers: Our customers are always guaranteed of papers that exceed their expectations. All our writers have +5 years of experience. This implies that all papers are written by individuals who are experts in their fields. In addition, the quality team reviews all the papers before sending them to the customers.
3. Plagiarism-Free Papers: All papers provided by Nursing Experts .org are written from scratch. Appropriate referencing and citation of key information are followed. Plagiarism checkers are used by the Quality assurance team and our editors just to double-check that there are no instances of plagiarism.
4. Timely Delivery: Time wasted is equivalent to a failed dedication and commitment. Nursing Experts .org is known for timely delivery of any pending customer orders. Customers are well informed of the progress of their papers to ensure they keep track of what the writer is providing before the final draft is sent for grading.
5. Affordable Prices: Our prices are fairly structured to fit in all groups. Any customer willing to place their assignments with us can do so at very affordable prices. In addition, our customers enjoy regular discounts and bonuses.
6. 24/7 Customer Support: Nursing Experts .org, we have put in place a team of experts who answer to all customer inquiries promptly. The best part is the ever-availability of the team. Customers can make inquiries anytime.

Menu
 
  • Home
  • About Us
  • Services
  • Prices
  • Guarantees
  • Contact Us
 
Free resources
 
  • Free Essays
  • Essay tips
  • Essay types
  • Plagiarism Checker
 
Dissertation help
 
  • Free consultation
  • Essay examples
  • Buy essay
  • Dissertation assistance
  • Free dissertations
  • Coursework help
 
nursingexperts.org  ©2017- 2021  All rights reserved. Terms of use | Privacy Policy