NSG 6435 Week 10 Pediatric SOAP Note Latest 2022/2023

Pediatric SOAP Note NP Student Name: Amanda Stott Child’s Initials: LR DOB: 08/18/2018 Clinical Date: 05/24/2019 Age: 9 months Place of Born: Logan, UT Week Soap Project: W1 W3 W6 W8 Sex: M _X_ F ___ Type of Soap Note: Well child visit __X_ Sick visit ____ SUBJECTIVE Historian: Mother Present Concerns/CC: (Reason given by the patient for seeking medical care “in quotes”) “Here for a 9 month well check.” Child Profile: (complete the areas listed as appropriate; may omit an area if not appropriate to the client) Activities of Daily Living ( ag e app op r i atre) : (include feeding, sleeping, bathing, dressing, chores, etc.) He needs help with all ADLs by his parents or caregivers. Sa f ety Practi c es : He rides in a 5-point harness car seat in the car. C ha n ges in d yacar e/ s c h ool /a f t er-sc h ool car e: He does not attend day care Sp r ot s / ph sical y act ivi t y: He is behind in activity D ev elop e mn tal History: (provide a history of development over the child’s lifespan. If child is 1y/o or younger, provide birth history also) He is developmentally delay and Up to 3 is working with him. He is not rolling over, crawling, or scooting, he is sitting up but still tips over. Sexu al Hi s t or (iy fpp a op r i atre ) : HPI: (must include all components) The patient presents to clinic today for their health care maintenance exam. The patient is accompanied in clinic today by their parent who is providing the history. There are not concerns today to discuss. The patient is eating well, and there are not concerns with their feeding habits. The patient's diet consists of a good variety of foods, and they take most foods well. They are growing well. They have had regular stools, and there are not concerns with diarrhea or constipation. They have had several wet diapers each day. They are sleeping through the night. Parents do not have developmental concerns. The patient is not crawling,