Pediatric SOAP Note
NP Student Name: Kayla Stevens Child’s Initials: ks DOB: 04/1/04 Clinical Date: 05/21/19 Age: 13 Place of Born: Douglas, GA Week Soap Project: 05/21/19 Sex: M _X F Type of Soap Note: Well child visit Sick visit _X SUBJECTIVE Historian: Parent and child Present Concerns/CC: “my toe hurts” Child Profile: (complete the areas listed as appropriate; may omit an area if not appropriate to the client) Activities of Daily Living (age appropriate): The patient feeds, clothes, dresses himself attends school, keeps a tidy room. Safety Practices: Uses seat belt, no guns in the home Nutrition: Eats three to four meals a day from a variety of food groups. Drinks about 2 sodas per day Changes in daycare/school/after-school care: NA Sleep: has a regular sleep routine during school months, likes to stay up late at night. Sports/physical activity: Plays baseball in the spring. Developmental History: - Gross and fine motor: Appropriate - Cognitive: Takes honors classes when in school does very well with grades. - Social/Emotional/Communication: has lots of friends that he socializes with regularly. SOCIAL: -Denies cigarettes, drugs, and Alcohol. Sexual History (if appropriate): Not sexually active.
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- August 17, 2021
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