Soap Note Assignment Paper

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Soap Note Assignment Paper

Medication Intolerances: None

Chronic Illnesses/Major traumas: None

Soap Note Assignment

Hospitalizations/Surgeries: None

Immunizations: up today

Father- 29years old. Alive and well

Grandmother :55 ,HTN ,Alive

OBJECTIVE

Eyes: Pupils PERRLA. Present red reflexes on both eyes

Ears: No tenderness. Pink tympanic membranes

Nose: Normal turbinates. Septum midline

Mouth: 2 bottom central incisors. Soap Note Assignment

Throat: No erythema of exudates

Neck: Supple without masses or thyroid enlargement

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Pediatric/Adolescent Assessment Tools (Ages & Stages, etc) with results and rationale

For adolescents (HEADSSSVG Assessment)

Assessment conducted during this visit: PEDS score of 0 (no concerns) Soap Note Assignment

Parents’ Evaluation of Developmental Status, or PEDS, is an evidence based screening tool that elicits and addresses parental concerns about children’s development, health and wellbeing. PEDS is a simple, 10-item questionnaire that is completed by the parent.

According to Woolfenden et al., (2014), this questionnaire in 95% is simple to understand in 95% of the parents no matter their background level or educations. Its purpose is to discover concerns and address certain areas of development with the appropriate timely referrals for follow up. Soap Note Assignment Paper

. Z 71.3: Dietary counseling and surveillance: Nutritional counseling can help improve dietary habits by increasing the average daily intake of essential components of a healthy diet – reductions in saturated fat consumption and increase in fiber, fruit and vegetable consumption. Counseling can be delivered by primary care clinicians or specialists including nutritionists and dieticians. Soap Note Assignment Paper

. Z23: Encounter for immunizations: This is an encounter for administration of the vaccination according to the child age and also for education regarding to what can diseases the child will develop immunization, schedule, side effect .

Primary Diagnosis:

. Z00.129: Well child exam

· DTaP,

· IPV,

· Hib,

· HepB,

· Rotateq,

· PCV 13

Education:

The education for this encounter, include the anticipatory guidance and this encompass:

Education of the mother regarding to the importance of preventive such as:

Vaccination education, schedule, and side effects, which are inflammation or redness sites after administrations, some low grade fever, and fussiness, (CDC, 2017). Soap Note Assignment Paper

Safety in the car and at home:

Have the smoked detector at home and may sure that they are working properly and changes the batteries.

Always before bathing check the water temperatures to ensure that is adequately.

Protect your child from injury. Use gates on stairways and doors. Install operable window guards on all windows above the first floor. Remove sharp-edged or hard furniture from the room where your child plays.

Place your baby’s crib away from windows. Cords from window blinds and draperies can strangle your child. Use cordless window coverings, or if this is not possible, tie cords high and out of reach. Do not knot cords together.

Use of car safety seats every time your child is in the car. All infants and toddlers should ride in a rear-facing car.

Nutrition: Introducing fruits, salads and veggies is important. Continue breastfeeding if desired and possible. Breast milk continues to provide excellent nutrition to the baby. Soap Note Assignment Paper

Anticipatory guidance

Dental care must be implanted as patient already has 2 teeth. Use a soft brush and clean with water twice daily

Avoid use of television or other technological devices for distraction

Reading and spending time with the baby as well as establishing a routine are excellent methods to ensure a healthy development

Next follow up appointment at 9 moths or as needs if there are any concerns.

Self -Evaluation for this encounter.

This is 6 months’ year old Hispanic female. She is a well develop child for her age, and for this encounter is Well child exam for healthy children, according to The Bright Futures/American Academy of Pediatrics (AAP) developed a set of comprehensive health guidelines for well-child care, known as the “periodicity schedule.” It is a schedule of screenings and assessments recommended at each well-child visit from infancy through adolescence. Soap Note Assignment. After I gathered the information in the interview for the mother and the physical examination I performed, I presented this well child case to my preceptor for discussion, who was agree with the proposed course of action. The mother was instructed the importance of this visit even if the child is normal because then us as a health care provider have the opportunity work together and tracking the growth and development of the child as well we can review together the child vaccination schedule besides if there is concern that could be arisen in topic of the development, behavior, sleep, eating, this visit gives us an opportunity to develop a team approach, regular visit develop strong and trustworthy relation between parent and health care provider. Mother is aware of the next appointment. Soap Note Assignment Paper

References:

Centers for Disease Control and Development [CDC] (2017, January 3). Child development: Developmental monitoring and screening for health professionals). Retrieved from https://www.cdc.gov/ncbddd/childdevelopment/screening-hcp.html. Soap Note Assignment

Woolfenden, S., Eapen, V., Williams, K., Hayen, A., Spencer, N., & Kemp, L. (2014). A systematic review of the prevalence of parental concerns measured by the parents’ evaluation of developmental status (PEDS) indicating developmental risk. BMC Pediatrics, 14(1), 231-244. doi:10.1186/1471-2431-14-231