NR 509 Week 6 Pediatric SOAP Note, Summer 2020 Complete
Solution
SOAP Note Template
S: Subjective
Information the patient or patient representative told you
a
Initials: D.R. Age: 8 Gender: male
vi
Height Weight BP HR RR Temp SPO2 Pain Allergies
4’2 90lbs 120/ 100 28 37.2c 96% Medication: Denies
d
per 76 Food: Denies
e
patient( Environment: Denies
ar
unable
to get a
sh
standin
g
weight.
as
History of Present Illness (HPI)
Chief Complaint (CC) Cough CC is a BRIEF statement identifying
w
Onset Cough started 5 days ago why the patient is here - in the
Location throat patient’s own words - for instance
"headache", NOT "bad headache for 3
m e
Duration Coughing every few minutes lasting 1-2min , for the past five days.
days”. Sometimes a patient has more
Characteristics
co rc
Productive cough rated a 5 out of 10 with clear and thin sputum, cough
worsens at night. Associated symptoms of sore throat and earache,(gargly and
than one complaint. For example: If
the patient presents with cough and
o. ou
watery associated with sore throat) sore throat, identify which is the CC
Aggravating Factors Worse at night. Reports cough stays the same no matter what I do. (cough at and which may be an associated
night think CHF, GERD, Asthma…) symptom
er res
Relieving Factors Cough medicine “helped a little”
Treatment resting
Current Medications: Include dosage, frequency, length of time used and reason for use; also include OTC or homeopathic products.
eH y
Medication Length of Time
rs ud
Dosage Frequency Reason for Use
(Rx, OTC, or Homeopathic) Used
Gummy multivitamin 2-4 gummies daily Unable to “to stay healthy”
answer my
t
ss
question when
asked.
Cough medicine “ a spoonful” One time “Once this AM” Cough
hi
N/A Click or tap here to Click or tap here to enter Click or tap here Click or tap here to enter text.
, enter text. text. to enter text.
N/A Click or tap here to Click or tap here to enter Click or tap here Click or tap here to enter text.
enter text. text. to enter text.
N/A Click or tap here to Click or tap here to enter Click or tap here Click or tap here to enter text.
enter text. text. to enter text.
a
vi
Past Medical History (PMHx) – Includes but not limited to immunization status (note date of last tetanus for all adults), past major illnesses,
hospitalizations, and surgeries. Depending on the CC, more info may be needed.
e d
-Reports frequent colds and Rhinorrhea. Reports no fever last few times mother checked temperature. Hx of frequent earaches at 2 yrs old.
-Pneumonia last year at 7 years old, missed school for 2 weeks, treated at an urgent care with unknown antibiotics (can’t recall the name).
ar
-Hearing checked 1 month ago at school: reports it was normal.
-Last dental visit 2 months ago: reports no cavities.
sh
-Denies any previous surgeries. Stated has tonsils still and no ear surgeries. Denies prior hospitalizations.
According to patient chart immunizations up to date at this time. No influenza vaccine, last 12 months.
Social History (Soc Hx) - Includes but not limited to occupation and major hobbies, family status, tobacco and alcohol use, and any other pertinent
as
data. Include health promotion such as use seat belts all the time or working smoke detectors in the house.
w
Student: 3rd grader. Only child.Exposed to second hand smoke by father who smokes inside the house sometimes.
Lives with Abeula (maternal grandmother), mother,Papi (father), and Abuelo (grandfather). Mother is a stenographer. Father is a security officer for
m e
court. States: “ I always feel safe at home. I have a good family!”. No pets in household. Reports drinks 7-8 glasses of water/ day. Goes to gym
co rc
class everyday at school for exercise and plays at the park after school or sometimes on weekends. Hobbies: play video games, read, try to write
stories with best friend Tony. Denies using tobacco or alcohol use.
o. ou
Family History (Fam Hx) - Includes but not limited to illnesses with possible genetic predisposition, contagious or chronic illnesses. Reason for
death of any deceased first degree relatives should be included. Include parents, grandparents, siblings, and children. Include grandchildren if
er res
pertinent.
Lives with grandparents and parents.
Mother: DM2, HTN,hypercholesterolemia, obesity.
eH y
Father: Current Smoker (couple of times a week, smokes inside) history of childhood asthma. HTN , hypercholesterolemia.
rs ud
Maternal Grandma:DM type 2, HTN
Maternal Grandpa: doesn’t see a doctor
Paternal grandma: died in a car accident (52yrs. Old)
t
ss
Paternal grandpa: unknown (estranged)
hi
Solution
SOAP Note Template
S: Subjective
Information the patient or patient representative told you
a
Initials: D.R. Age: 8 Gender: male
vi
Height Weight BP HR RR Temp SPO2 Pain Allergies
4’2 90lbs 120/ 100 28 37.2c 96% Medication: Denies
d
per 76 Food: Denies
e
patient( Environment: Denies
ar
unable
to get a
sh
standin
g
weight.
as
History of Present Illness (HPI)
Chief Complaint (CC) Cough CC is a BRIEF statement identifying
w
Onset Cough started 5 days ago why the patient is here - in the
Location throat patient’s own words - for instance
"headache", NOT "bad headache for 3
m e
Duration Coughing every few minutes lasting 1-2min , for the past five days.
days”. Sometimes a patient has more
Characteristics
co rc
Productive cough rated a 5 out of 10 with clear and thin sputum, cough
worsens at night. Associated symptoms of sore throat and earache,(gargly and
than one complaint. For example: If
the patient presents with cough and
o. ou
watery associated with sore throat) sore throat, identify which is the CC
Aggravating Factors Worse at night. Reports cough stays the same no matter what I do. (cough at and which may be an associated
night think CHF, GERD, Asthma…) symptom
er res
Relieving Factors Cough medicine “helped a little”
Treatment resting
Current Medications: Include dosage, frequency, length of time used and reason for use; also include OTC or homeopathic products.
eH y
Medication Length of Time
rs ud
Dosage Frequency Reason for Use
(Rx, OTC, or Homeopathic) Used
Gummy multivitamin 2-4 gummies daily Unable to “to stay healthy”
answer my
t
ss
question when
asked.
Cough medicine “ a spoonful” One time “Once this AM” Cough
hi
N/A Click or tap here to Click or tap here to enter Click or tap here Click or tap here to enter text.
, enter text. text. to enter text.
N/A Click or tap here to Click or tap here to enter Click or tap here Click or tap here to enter text.
enter text. text. to enter text.
N/A Click or tap here to Click or tap here to enter Click or tap here Click or tap here to enter text.
enter text. text. to enter text.
a
vi
Past Medical History (PMHx) – Includes but not limited to immunization status (note date of last tetanus for all adults), past major illnesses,
hospitalizations, and surgeries. Depending on the CC, more info may be needed.
e d
-Reports frequent colds and Rhinorrhea. Reports no fever last few times mother checked temperature. Hx of frequent earaches at 2 yrs old.
-Pneumonia last year at 7 years old, missed school for 2 weeks, treated at an urgent care with unknown antibiotics (can’t recall the name).
ar
-Hearing checked 1 month ago at school: reports it was normal.
-Last dental visit 2 months ago: reports no cavities.
sh
-Denies any previous surgeries. Stated has tonsils still and no ear surgeries. Denies prior hospitalizations.
According to patient chart immunizations up to date at this time. No influenza vaccine, last 12 months.
Social History (Soc Hx) - Includes but not limited to occupation and major hobbies, family status, tobacco and alcohol use, and any other pertinent
as
data. Include health promotion such as use seat belts all the time or working smoke detectors in the house.
w
Student: 3rd grader. Only child.Exposed to second hand smoke by father who smokes inside the house sometimes.
Lives with Abeula (maternal grandmother), mother,Papi (father), and Abuelo (grandfather). Mother is a stenographer. Father is a security officer for
m e
court. States: “ I always feel safe at home. I have a good family!”. No pets in household. Reports drinks 7-8 glasses of water/ day. Goes to gym
co rc
class everyday at school for exercise and plays at the park after school or sometimes on weekends. Hobbies: play video games, read, try to write
stories with best friend Tony. Denies using tobacco or alcohol use.
o. ou
Family History (Fam Hx) - Includes but not limited to illnesses with possible genetic predisposition, contagious or chronic illnesses. Reason for
death of any deceased first degree relatives should be included. Include parents, grandparents, siblings, and children. Include grandchildren if
er res
pertinent.
Lives with grandparents and parents.
Mother: DM2, HTN,hypercholesterolemia, obesity.
eH y
Father: Current Smoker (couple of times a week, smokes inside) history of childhood asthma. HTN , hypercholesterolemia.
rs ud
Maternal Grandma:DM type 2, HTN
Maternal Grandpa: doesn’t see a doctor
Paternal grandma: died in a car accident (52yrs. Old)
t
ss
Paternal grandpa: unknown (estranged)
hi
