NSG 6435 Week 1 Soap Note Latest Comprehensive

NSG 6435 Week 1 Soap Note Latest Comprehensive PEDIATRIC FILLABLE SOAP NOTE TEMPLATE STUDENT NAME: Amy Brown DATE OF ASSIGNMENT: 02/27/2019 Patient Initials: K.L. Date of Encounter: 02/21/2019 Sex: Female Age: 22 months DOB: 4/17/2017 Place of Birth: Cape Coral Florida SUBJECTIVE Historian: Mother Present Concerns/CC: “K.L. has had a cough, congestion, fever and wheezing x5 days”  Child Profile: Child has met all milestones for 22 months:  No family stressors at home, child lives with both mother and father  ADLs: feeds self, help with undressed/dressed, helps with brushing teeth, wash/dry hands, toilet trained during the day, wakes up most mornings dry  Distinguishing between edible and inedible objects  Looking in the right spot for hidden objects  Playing next to children  Imitating adult behavior  Engaging in imaginative play  Has an awareness of a parent’s approval or disapproval  Sleep: 11hrs/night, self-soothing, in her own room  Nutrition: favorite foods: bananas, grilled cheese, hydration: drinks from sippy cup, milk with meals, water the rest of the day, no juice, minimal junk food, mother cooks meals daily  Safety: in rear facing car seat, not exposed to second hand smoke, no paternal history of etoh or substance abuse, no guns in the home.  Understanding common dangers of hot objects, stairs, glass  Regularly checking in with adults  Knowing where familiar items are kept  Removing own shoes and socks  Cooperating with dressing by extending an arm