NSG 6435 Comprehensive SOAP Note Stevens.K Week 9

NSG 6435 Comprehensive SOAP Note Stevens.K Week 9 Pediatric SOAP Note NP Student Name: Kayla Stevens Child’s Initials: LD DOB: 03/04/201 Clinical Date: 06/25/2019 Age: 5 Place of Born: Douglas, GA Week Soap Project: W9 Sex: M ___ F _X__ Type of Soap Note: Well child visit __X__ Sick visit ____ SUBJECTIVE Historian: Parent Present Concerns/CC: “She is here for her well-check, I think she has allergies”. Child Profile: (complete the areas listed as appropriate; may omit an area if not appropriate to the client) Activities of Daily Living (a ge app o pr i atr e): The child dresses independently but does sometimes need help matching outfits. The child brushes teeth independently at least twice per day. The child is learning to tie shoes but does require help. The child settles for sleep independently. The child sleeps in her own bed. The child feeds self without difficulty. Sa f e ty Pract i c e s: Home is childproofed with covers on electrical outlets, uses booster seat, able to swim, mother states sunscreen is used, -tobacco/ETOH abuse, -falls, -lead, - TB exposure Nutrition: Mother states that the child drinks 2% milk at least one cup daily. Mother states the child does drink juices and koolaids. States that she attempts to ensure that the child drinks as much water as possible. States the child’s taste in food changes from day to day, but she does try to ensure that she east plenty of fruits and vegetables. C ha n s gei n dycaa r e / s c h ool /a f t er-sc h l oocar e: Stays at home with mother during the day while father works. Will be attending kindergarten in the fall. Sleep: The child sleeps in her bed at night and usually goes to sleep around 9 pm and wakes up at 8 am. Mother reports child sleeps through the night. Does take one nap per day. Sp o r t s /ph sical y act i vit y: NA D e v elop me n tal History: - Gross motor: Hops, Skips, rides bicycle with training wheels, swims with no floaties. - Fine motor: uses scissors, colors in the lines, can draw simple objects, manages buttons and zippers - Cognitive: Follows simple directions, can draw shapes, knows colors, knows alphabet - Social/Emotional: plays well with other children, able to follow the rules of games such as “Simon Says”. - Communication: Has a large vocabulary. Clearly and easily understood. Sexu al Hi s t o r (iy fp pa op r r i at e ):NA HPI: The patient is a 5 year old Hispanic female who presents with her mother for her 5 year old health check. Mother states she feels as though she is “doing well”. States that she feels as though she is progressing quicker developmentally than her son did when he was her age. States that her current favorite food is chicken nuggets, but she does ensure that the child has at least one well-balanced meal per day. States that the child does sleep in her bed alone, but still requires her favorite stuffed animal she has had since she was two years old to be in the bed with her. States she sleeps with a night light on. Mother states she is concerned that her child has “allergies”. Child states “my nose is stuffy and I sneeze after being outside a lot”. Mother states they do live near pecan trees which she fears is the cause of the allergies. Denies any further complaints at present. Medications: No prescribed medications. Mother states she does give her OTC Children’s Tylenol and Motrin as needed for pain or fever. Revised 5/9/18; 8/9/18; 10/29/18 This study source was downloaded by from CourseH on :07:15 GMT -06:00 Pediatric SOAP Note PMH: Allergies: NKDA Chronic Illnesses/Major traumas: None reported Hospitalizations/Surgeries: None reported Immunizations: Up-to-date Family Medical History (Identify all immediate family members, their age, & health status) Mother: 27-year-old Hispanic female with no known health problems. Father: 34-year- Hispanic male with no known health problems. Older sibling (10 year old male)- no known health problems Social History (complete the areas listed as appropriate; may omit an area if not appropriate to the client) Cur r e nt livi n sg itu a t ion / p-a t nr r /e m a i t ra s lt a ut: Lives at home with mother, father, and older sibling. s Ed uc a iotnal le v el (as appropriate): NA Occupa t iona l hi s t o y (as appropriate) r : NA S ub tans ce u e /sabu es(ETOH, tobacco, and marijuana): NA Firearms in home: Father has guns which mother states is stored in a locked safe S a e tyf s t a ut: Home is childproofed with covers on electrical outlets, uses booster seat, able to swim, mother states s sunscreen is used, -tobacco/E