4 months old baby coming in for immunization vaccines
4 months old baby coming in for immunization vaccines
Submit a Well-child SOAP note for grading. You must use an actual patient from your clinical practicum.
Use the format below for your SOAP note as a reference and add/edit as needed depending on the age of the child/baby
You may refer to the following websites for additional information on the recommended schedule:
Healthy Children.orgLinks to an external site.Links to an external site.https://www.cdc.gov/vaccines/parents/visit/vaccination-during-COVID-19.html
https://brightfutures.aap.org/families/Pages/Well-Child-Visits.aspx
Well-child SOAP Note Format
Demographic Data
- Age, and gender (must be HIPAA compliant)
Subjective
- ___-day/week old infant/child accompanied by ___________ and here for a routine well-child/baby check (and vaccines). Any parental concerns/ questions today?
- Interval Events/History:
- Nutrition:
- Elimination:
- Sleep:
- Medications:
- Allergies:
- Past Medical
-
- Pregnancy and delivery?
- Surgeries, hospitalizations, or serious illnesses to date?
- Immunizations?
- Development: (describe as applicable to age)
-
- Gross motor:
-
- Fine motor:
- Cognitive:
- Social/Emotional:
- Communication:
- Social History:
- Smoking in the home?
- Family life/structure/dynamics? Primary caregivers?
- Stressors?
- Family History:
Objective (Should be a thorough head to toe assessment)
- Vital Signs/growth measurements (weight, length, head circumference, BMI, BP, HR, etc. if applicable)
-
- Physical findings listed by body systems, not paragraph form.
- Highlight abnormal findings
- Growth Chart Percentages: if applicable
- Labs/Studies: if applicable
Assessment
- Well-child visit ICD10 code(s)
Plan
- Vaccines today:
- Anticipatory guidance (discussed or covered in the visit)?
- Health Maintenance
- Return precautions?
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