SOAP NOTE WEEK 9 - PEDIATRIC FILLABLE SOAP NOTE TEMPLATE

SOAP NOTE WEEK 9 - PEDIATRIC FILLABLE SOAP NOTE TEMPLATE Student Name: Yanela Molina- Chuy Date of Assignment: 06/27/2022 Patient Initials: MR Date of Encounter: 06/26/2022 Sex: Female Age: 4 years SUBJECTIVE Historian: Given for her mother Present Concerns/CC: “ Rash and Mouth Pain” Child Profile: (Sexual History (If appropriate); ADLs (age appropriate); Safety Practices; Changes in daycare/school/after-school care; Sports/physical activity; Developmental Hx) HPI: Patient is a 4-year male that came to the clinic with her mother. Mother says that her daughter started almost 1 week ago with a rash in her mouth. Mother reports that the lesions begin as papules that then progress to vesicles surrounded by erythema. Mother changed the body wash gel that had been using looking for changes without improved. Patient do not have any previous history of the rash and non-allergies know. Pain had been treated with ibuprofen. Medications Ibuprofen 10mg orally every 6 to 8 hours as needed for pain.