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May 17, 2024

Well child soap note

Well-Child SOAP Note Student name: Patient name (initials only): Ethnicity: Course: Date: Age: SUBJECTIVE Sex: CC: Well-child visit HPI: Medications: Past medical history: Allergies: Birth hx: . Immunizations: Hospitalizations: Past surgical history: Social history: Developmental Assessment: FAMILY HISTORY Mother: MGM: MGF: Father: PGM: PGF: General: Skin: Eyes: Ears: Nose/Mouth/Throat: Breast: Heme/Lymph/Endo: Weight: Height: General appearance: Skin: HEENT: Cardiovascular: Respiratory: Gastrointestinal: Genitourinary: Musculoskeletal: Neurological: BMI: ROS Cardiovascular: Respiratory: Gastrointestinal: Genitourinary/Gynecological: Musculoskeletal: Neurological: Psychiatry: OBJECTIVE BP: Temp: Pulse: Resp: Psychiatric: Labs performed in office the day of visit: None Differential diagnoses: 1. Diagnosis, (ICD 10 code and reference): Diagnosis Diagnosis : 2. Diagnosis, (ICD 10 code and reference): Plan/therapeutics/diagnostics; Education provided: CPT Code: Anticipatory guidance References

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