lOMoARcPSD|67691079
SOAP Note Form
S/ Identifying Information: (initials, Family Hx:
age/DOB, gender, reliability)
A.M. A.M. is the first-born child of three. Term birth.
3 years old Siblings are twins who were premature and required extensive NICU
Female time (and just last week the second infant came home with a g-tube
An existing patient and oxygen).
Presenting in Clinic with her mother, Mother and father are married. No health issues are verbalized by
who is considered to be a reliable parents, no one else in the home has been sick.
source and historian
Personal/Social Hx:
Chief Complaint/RFE: Daycare since she was 6 mo. old
Here for a sick visit New daycare in the past month (one that will eventually take all 3
Complaint of “fever and sore throat” children in the family)
Since the change in daycares, mother has noted regression, more
baby talk, and reports the child biting someone recently at school
A.M. eats a toddler diet. Drinks from a cup.
Speaks well with her friends and family.
Normally playful, but lately has had a harder time at this new school
and has been very clingy and hard to get her to go into the school in
the morning and has been crying more recently.
The family lives upstairs in a 2-bedroom apartment. Mother reports it
being tight right now with the twins.
Mother was working before she got pregnant but is now having to
stay home.
Father works outside the home in retail and is gone long hours.
No parental smoking
Grandma (maternal mother) is taking care of twins while patient and
patient mother are here in clinic. Mother reports this is the first time
leaving twins, expresses worrisome and anxiousness about situation.
Hx Present Illness:
(7 Variables but do not list as such)
A. M.’s mother reported her being in a normal state of health until 3 days ago when she returned home from
daycare with a mild runny nose. Her mother reports that over the past 3 days the nasal drainage has increased,
she has developed a cough, sore throat, her voice has changed, and last night she had a low-grade fever (tactile)
when she came home from daycare. The mother then reports that during the night she woke up crying and hot,
mother noted a temperature of 103.1 F (axillary). She was given Motrin 7mL, mother reports A.M was still
restless but went back to sleep and upon waking up this morning, noted to be later than normal, has not had her
normal energy, has had about 2 oz. of milk, no food intake today, has been irritable, and just wants to be held.
Nasal drainage stated as clear but reported today a yellow and thick, requiring help blowing her nose, nose is
red and irritated, and when mother tried to wipe her nose, the child deflected and ran to the chair in the clinic.
The child’s temperature came down some after the Motrin was given, but the child feels hot again at time of
visit. No vomiting or diarrhea noted with these symptoms. No rash noted. Mother denies anyone else in
household being sick. Mother expresses worrisome and anxiousness about being away from twins and wanting
to get a prescription and get out of clinic today. Mother says her friend’s child who is in the same class as A.M
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was given an antibiotic for the same symptoms last week, and she is better so they just need a quick visit to get
the antibiotic and she will need to get home to relieve grand mom from watching her twins.
CURRENT HEALTH
Medications: denies routine medications. AM Tylenol and Motrin if needed (but mother reports not knowing
the amount that she should give for A.M’s weight). Mother reported given the patient 7mL of Motrin last night.
Allergies: NKDA
Last PE & Screenings: last seen in the clinic 2 months ago for her 3-year-old well child visit, has had routine
wellness exams since birth in this clinic.
Immunization Status: Up to date for her age
LMP & Birth Control (if applicable) N/A
PMH
Illnesses & Trauma: Intermittent sick concerns, mainly respiratory in nature, and one visit for a fall (no details
provided on the nature and consequences of fall). Denies chronic health issues.
Hospitalizations/Surgeries denies history
OB Hx/Sexual Hx: denies history
Emotional/Psychiatric Hx: The patients mother reports noticing recent behavioral changes including
regression, increased baby talk, and biting in the patient, along with difficulty with school transition, increased
clinginess and crying during mornings at school. Denies emotional or psychiatric history prior to recent school
transition.
REVIEW OF SYSTEMS
General
Fever, decreased energy, restlessness sleep, irritability, difficulty with school transition
Nutrition
Patient is reported to eat a toddler diet and drinks milk. Patients mother reports decreased food and fluid intake,
reported that the patient only had about 2 ounces of milk with no food intake today.
Can you describe a typical day of meals and snacks for your toddler?
What beverages does your toddler typically consume? How much water, milk, or juice do they drink daily?
Is your toddler taking any vitamin or mineral supplements?
Skin/Hair/Nails
Nasal redness and irritation
Have you noticed any new skin rashes?
HEENT
Voice changes, nasal congestion, increased nasal drainage (yellow and thick)
Has she mentioned having a headache?
Has she been tugging on her ear(s)?
Have you noticed any eye discharge?
Breasts
Have you noticed any pain to touch? Tenderness to touch? or lumps?
Respiratory
Nasal congestion, increased nasal drainage (yellow and thick), cough
Is your child experiencing any difficulty breathing or shortness of breath at rest and/or with exertion? Is it a
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SOAP Note Form
S/ Identifying Information: (initials, Family Hx:
age/DOB, gender, reliability)
A.M. A.M. is the first-born child of three. Term birth.
3 years old Siblings are twins who were premature and required extensive NICU
Female time (and just last week the second infant came home with a g-tube
An existing patient and oxygen).
Presenting in Clinic with her mother, Mother and father are married. No health issues are verbalized by
who is considered to be a reliable parents, no one else in the home has been sick.
source and historian
Personal/Social Hx:
Chief Complaint/RFE: Daycare since she was 6 mo. old
Here for a sick visit New daycare in the past month (one that will eventually take all 3
Complaint of “fever and sore throat” children in the family)
Since the change in daycares, mother has noted regression, more
baby talk, and reports the child biting someone recently at school
A.M. eats a toddler diet. Drinks from a cup.
Speaks well with her friends and family.
Normally playful, but lately has had a harder time at this new school
and has been very clingy and hard to get her to go into the school in
the morning and has been crying more recently.
The family lives upstairs in a 2-bedroom apartment. Mother reports it
being tight right now with the twins.
Mother was working before she got pregnant but is now having to
stay home.
Father works outside the home in retail and is gone long hours.
No parental smoking
Grandma (maternal mother) is taking care of twins while patient and
patient mother are here in clinic. Mother reports this is the first time
leaving twins, expresses worrisome and anxiousness about situation.
Hx Present Illness:
(7 Variables but do not list as such)
A. M.’s mother reported her being in a normal state of health until 3 days ago when she returned home from
daycare with a mild runny nose. Her mother reports that over the past 3 days the nasal drainage has increased,
she has developed a cough, sore throat, her voice has changed, and last night she had a low-grade fever (tactile)
when she came home from daycare. The mother then reports that during the night she woke up crying and hot,
mother noted a temperature of 103.1 F (axillary). She was given Motrin 7mL, mother reports A.M was still
restless but went back to sleep and upon waking up this morning, noted to be later than normal, has not had her
normal energy, has had about 2 oz. of milk, no food intake today, has been irritable, and just wants to be held.
Nasal drainage stated as clear but reported today a yellow and thick, requiring help blowing her nose, nose is
red and irritated, and when mother tried to wipe her nose, the child deflected and ran to the chair in the clinic.
The child’s temperature came down some after the Motrin was given, but the child feels hot again at time of
visit. No vomiting or diarrhea noted with these symptoms. No rash noted. Mother denies anyone else in
household being sick. Mother expresses worrisome and anxiousness about being away from twins and wanting
to get a prescription and get out of clinic today. Mother says her friend’s child who is in the same class as A.M
messages.pdf_cover_qr_code_label
messages.downloaded_by
, lOMoARcPSD|67691079
was given an antibiotic for the same symptoms last week, and she is better so they just need a quick visit to get
the antibiotic and she will need to get home to relieve grand mom from watching her twins.
CURRENT HEALTH
Medications: denies routine medications. AM Tylenol and Motrin if needed (but mother reports not knowing
the amount that she should give for A.M’s weight). Mother reported given the patient 7mL of Motrin last night.
Allergies: NKDA
Last PE & Screenings: last seen in the clinic 2 months ago for her 3-year-old well child visit, has had routine
wellness exams since birth in this clinic.
Immunization Status: Up to date for her age
LMP & Birth Control (if applicable) N/A
PMH
Illnesses & Trauma: Intermittent sick concerns, mainly respiratory in nature, and one visit for a fall (no details
provided on the nature and consequences of fall). Denies chronic health issues.
Hospitalizations/Surgeries denies history
OB Hx/Sexual Hx: denies history
Emotional/Psychiatric Hx: The patients mother reports noticing recent behavioral changes including
regression, increased baby talk, and biting in the patient, along with difficulty with school transition, increased
clinginess and crying during mornings at school. Denies emotional or psychiatric history prior to recent school
transition.
REVIEW OF SYSTEMS
General
Fever, decreased energy, restlessness sleep, irritability, difficulty with school transition
Nutrition
Patient is reported to eat a toddler diet and drinks milk. Patients mother reports decreased food and fluid intake,
reported that the patient only had about 2 ounces of milk with no food intake today.
Can you describe a typical day of meals and snacks for your toddler?
What beverages does your toddler typically consume? How much water, milk, or juice do they drink daily?
Is your toddler taking any vitamin or mineral supplements?
Skin/Hair/Nails
Nasal redness and irritation
Have you noticed any new skin rashes?
HEENT
Voice changes, nasal congestion, increased nasal drainage (yellow and thick)
Has she mentioned having a headache?
Has she been tugging on her ear(s)?
Have you noticed any eye discharge?
Breasts
Have you noticed any pain to touch? Tenderness to touch? or lumps?
Respiratory
Nasal congestion, increased nasal drainage (yellow and thick), cough
Is your child experiencing any difficulty breathing or shortness of breath at rest and/or with exertion? Is it a
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