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

https://www.healthychildren.org/English/family-life/health-management/Pages/Well-Child-Care-A-Check-Up-for-Success.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?