Patient is a 14 year old who came in today complaining of sore throat for 3 days. Patient denies any fever, cough or SOB at this time. Lung sounds clear to a
SOAP note. Rubric, SOAP note template and previous instructor feedback provided. APA format. use evidence based practice and CDC guidelines
Case for soap note: 14 year old Male
Patient is a 14 year old who came in today complaining of sore throat for 3 days. Patient denies any fever, cough or SOB at this time. Lung sounds clear to auscultation, erythematous throat, tonsils +1 BL, no cervical lymphedema noted during assessment. Patient instructed to Gargling with Salt Water at least twice a day for sore throat. Tylenol and Motrin over the for sore throat and if fever. If symptoms worsen or persist to call back the office.
J02.9 | Acute pharyngitis, unspecified
Subjective, Objective, Assessment, Plan (SOAP) Notes
Student name: |
Course: |
Patient name (initials only): |
Date: Time: |
Ethnicity: |
Age: Sex: |
SUBJECTIVE |
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CC: |
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HPI: |
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Medications: |
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Past medical history: |
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Allergies: |
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Birth hx: (use only on well child visits): |
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Immunizations: |
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Hospitalizations: |
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Past surgical history: |
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Social history: |
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Developmental Assessment: (include on well child visit only but may be necessary for problem focused notes) |
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FAMILY HISTORY |
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Mother: |
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MGM: |
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MGF: |
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Father: |
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PGM: |
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PGF: |
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REVIEW OF SYSTEMS |
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General: |
Cardiovascular: |
Skin: |
Respiratory: |
Eyes: |
Gastrointestinal: |
Ears: |
Genitourinary/Gynecological: |
Nose/Mouth/Throat: |
Musculoskeletal: |
Breast: Heme/Lymph/Endo: |
Neurological: |
Psychiatry: |
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OBJECTIVE (Document PERTINENT systems only, Minimum 3 for problem focused, all systems for well child exam) |
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Weight: Height: BMI: BP: Temp: Pulse: Resp: (Insert plotted growth chart below on all well child soap notes) |
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General appearance: |
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Skin: |
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HEENT: |
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Cardiovascular: |
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Respiratory: |
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Gastrointestinal: |
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Genitourinary: |
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Musculoskeletal: |
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Neurological: |
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Psychiatric: |
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Labs performed in office the day of visit: |
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Diagnosis (must complete this section and explain how all differential diagnoses were ruled in or ruled out) |
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Differential diagnoses: 1. Diagnosis, (ICD 10 code and reference): 2. Diagnosis, (ICD 10 code and reference): 3. Diagnosis (ICD 10 code and reference): |
Diagnosis (ICD 10 code and reference): |
Plan/therapeutics/diagnostics; |
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Education provided: |
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CPT Code: |
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Anticipatory guidance (well child visit only) |
References:
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PEDS SOAP NOTE PEARLS
· HPI – always include assessment of diet, activity, elimination, sleep
· If has temp always document how temp was take- oral, axilla etc and what was last temp
· If had any meds get name, dose, last time given
· Ensure to include ALL aspects of OLDCARTS
· PE
· Every exam WCC or focused should include a skin assessment. Skin intact to thorax, bilateral UE and LE, no bruising, ecchymosis of skin tears noted.
· Include completes assessment for HEENT
· Head- ensure to examine fontanelles and document if open/closed
· Eyes-ensure to document complete assessment
· Ears-ensure to include cones of light exam
· Nose-ensure to include bilateral nare exam
· Sinus- ensure to include complete sinus exam
· Mouth- ensure to include buccal mucosa, dentition
· Throat- ensure complete exam
· Tonsil- ensure proper grading using tonsil scale
· Lymph nodes-document names of all lymph nodes head and neck and their assessment
· Cardio- ensure have S1, S2, no M/R/G
· Lungs- CTA bilateral UL/LL/laterally, anterior and posterior
· MSK- ensure to document proper strength scale 5+/5+, etc
· Reflexes- ensure to document proper scale 2+/2+, etc
· Assessment
· Need to provide rationale for all diff dx and final dx- how were they ruled in/out
· Plan
· Need detailed patient education- saying educated oh healthy diet not enough- need specifics- exactly what should their diet include
· Ensure to have ER precautions and specifics of when the patient should follow-up and why
· Anticipatory guidance should be included in all WCC- use Bright Futures resources
· All medication should include education on medication side effects
· All WCC need to have growth chart properly documented and plotted
** Details are important- If is was not documented it was not done.**
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