Assignment Prompt & Instructions
APA format, evidence based practice. Due in 24 hrs. Previous soap note and feedback from instructor provided.
– ## PEDSSOAPNoteTemplateweek5.docx
– feedbackfocusedWeek3-pedssoapnotetemplate1.docx
**## PEDSSOAPNoteTemplateweek5.docx**
J06.9 | Acute upper respiratory infection, unspecified
J30.9 | Allergic rhinitis, unspecified
Patient 13 months old comes in with mom for complains of wet cough that started on 5/23 with decreased activity, voice changed and decreased appetite . Patient voice change ,activity level and appetite resolved. Patient started to have nasal congestion yesterday 5/28/25. Patient mom denies any fever, rash, signs of ear pain.
A: nasal congestion noted, ears TMs pearly clear BL,
throat not irritated, BL tonsils +1
RUL, RML, RLL, LUL, LLL lung fields clear
TX: Increase fluid intake over the counter ibuprofen to treat fever and body aches
F/U in 9 months for annual exam or PRN if symptoms worsen
**Subjective, Objective, Assessment, Plan (SOAP) Notes**
| | |
| — | — |
| **Student name:** | **Course:** |
| **Patient name (initials only):** | **Date: Time:** |
| **Ethnicity:** | **Age: Sex:** |
| **SUBJECTIVE** |
| **CC:** |
| **HPI:** |
| **Medications:** |
| **Past medical history:** |
| **Allergies:** |
| **Birth hx: (use only on well child visits):** |
| **Immunizations:** |
| **Hospitalizations:** |
| **Past surgical history:** |
| **Social history:** |
| **Developmental Assessment: (include on well child visit only but may be necessary for problem focused notes)** |
| **FAMILY HISTORY** |
| **Mother:** |
| **MGM:** |
| **MGF:** |
| **Father:** |
| **PGM:** |
| **PGF:** |
| |
| **REVIEW OF SYSTEMS** |
| **General:** | **Cardiovascular:** |
| **Skin:** | **Respiratory:** |
| **Eyes:** | **Gastrointestinal:** |
| **Ears:** | **Genitourinary/Gynecological:** |
| **Nose/Mouth/Throat:** | **Musculoskeletal:** |
| **Breast: Heme/Lymph/Endo:** | **Neurological:** |
| | **Psychiatry:** |
| **OBJECTIVE (Document PERTINENT systems only, Minimum 3 for problem focused, all systems for well child exam)** |
| **Weight: Height: BMI: BP: Temp: Pulse: Resp:**<br>**(Insert plotted growth chart below on all well child soap notes)** |
| **General appearance:** |
| **Skin:** |
| **HEENT:** |
| **Cardiovascular:** |
| **Respiratory:** |
| **Gastrointestinal:** |
| **Genitourinary:** |
| **Musculoskeletal:** |
| **Neurological:** |
| **Psychiatric:** |
| **Labs performed in office the day of visit:** |
| |
| **Diagnosis (must complete this section and explain how all differential diagnoses were ruled in or ruled out)** |
| **Differential diagnoses:**<br>1. Diagnosis, (ICD 10 code and reference):<br>2. Diagnosis, (ICD 10 code and reference):<br>3. Diagnosis (ICD 10 code and reference): | **Diagnosis**(ICD 10 code and reference): |
| **Plan/therapeutics/diagnostics;** |
| **Education provided:** |
| **CPT Code:** |
| **Anticipatory guidance (well child visit only)** |
**References:**
**feedbackfocusedWeek3-pedssoapnotetemplate1.docx**
This file is too large to display. [View in new window](https://www.sweetstudy.com/files/feedbackfocusedweek3-pedssoapnotetemplate1-docx)
**feedbackfocusedWeek3-pedssoapnotetemplate1.docx**
This file is too large to display. [View in new window](https://www.sweetstudy.com/files/feedbackfocusedweek3-pedssoapnotetemplate1-docx)
**## PEDSSOAPNoteTemplateweek5.docx**
J06.9 | Acute upper respiratory infection, unspecified
J30.9 | Allergic rhinitis, unspecified
Patient 13 months old comes in with mom for complains of wet cough that started on 5/23 with decreased activity, voice changed and decreased appetite . Patient voice change ,activity level and appetite resolved. Patient started to have nasal congestion yesterday 5/28/25. Patient mom denies any fever, rash, signs of ear pain.
A: nasal congestion noted, ears TMs pearly clear BL,
throat not irritated, BL tonsils +1
RUL, RML, RLL, LUL, LLL lung fields clear
TX: Increase fluid intake over the counter ibuprofen to treat fever and body aches
F/U in 9 months for annual exam or PRN if symptoms worsen
**Subjective, Objective, Assessment, Plan (SOAP) Notes**
| | |
| — | — |
| **Student name:** | **Course:** |
| **Patient name (initials only):** | **Date: Time:** |
| **Ethnicity:** | **Age: Sex:** |
| **SUBJECTIVE** |
| **CC:** |
| **HPI:** |
| **Medications:** |
| **Past medical history:** |
| **Allergies:** |
| **Birth hx: (use only on well child visits):** |
| **Immunizations:** |
| **Hospitalizations:** |
| **Past surgical history:** |
| **Social history:** |
| **Developmental Assessment: (include on well child visit only but may be necessary for problem focused notes)** |
| **FAMILY HISTORY** |
| **Mother:** |
| **MGM:** |
| **MGF:** |
| **Father:** |
| **PGM:** |
| **PGF:** |
| |
| **REVIEW OF SYSTEMS** |
| **General:** | **Cardiovascular:** |
| **Skin:** | **Respiratory:** |
| **Eyes:** | **Gastrointestinal:** |
| **Ears:** | **Genitourinary/Gynecological:** |
| **Nose/Mouth/Throat:** | **Musculoskeletal:** |
| **Breast: Heme/Lymph/Endo:** | **Neurological:** |
| | **Psychiatry:** |
| **OBJECTIVE (Document PERTINENT systems only, Minimum 3 for problem focused, all systems for well child exam)** |
| **Weight: Height: BMI: BP: Temp: Pulse: Resp:**<br>**(Insert plotted growth chart below on all well child soap notes)** |
| **General appearance:** |
| **Skin:** |
| **HEENT:** |
| **Cardiovascular:** |
| **Respiratory:** |
| **Gastrointestinal:** |
| **Genitourinary:** |
| **Musculoskeletal:** |
| **Neurological:** |
| **Psychiatric:** |
| **Labs performed in office the day of visit:** |
| |
| **Diagnosis (must complete this section and explain how all differential diagnoses were ruled in or ruled out)** |
| **Differential diagnoses:**<br>1. Diagnosis, (ICD 10 code and reference):<br>2. Diagnosis, (ICD 10 code and reference):<br>3. Diagnosis (ICD 10 code and reference): | **Diagnosis**(ICD 10 code and reference): |
| **Plan/therapeutics/diagnostics;** |
| **Education provided:** |
| **CPT Code:** |
| **Anticipatory guidance (well child visit only)** |
**References:**
**feedbackfocusedWeek3-pedssoapnotetemplate1.docx**
This file is too large to display. [View in new window](https://www.sweetstudy.com/files/feedbackfocusedweek3-pedssoapnotetemplate1-docx)
**## PEDSSOAPNoteTemplateweek5.docx**
J06.9 | Acute upper respiratory infection, unspecified
J30.9 | Allergic rhinitis, unspecified
Patient 13 months old comes in with mom for complains of wet cough that started on 5/23 with decreased activity, voice changed and decreased appetite . Patient voice change ,activity level and appetite resolved. Patient started to have nasal congestion yesterday 5/28/25. Patient mom denies any fever, rash, signs of ear pain.
A: nasal congestion noted, ears TMs pearly clear BL,
throat not irritated, BL tonsils +1
RUL, RML, RLL, LUL, LLL lung fields clear
TX: Increase fluid intake over the counter ibuprofen to treat fever and body aches
F/U in 9 months for annual exam or PRN if symptoms worsen
**Subjective, Objective, Assessment, Plan (SOAP) Notes**
| | |
| — | — |
| **Student name:** | **Course:** |
| **Patient name (initials only):** | **Date: Time:** |
| **Ethnicity:** | **Age: Sex:** |
| **SUBJECTIVE** |
| **CC:** |
| **HPI:** |
| **Medications:** |
| **Past medical history:** |
| **Allergies:** |
| **Birth hx: (use only on well child visits):** |
| **Immunizations:** |
| **Hospitalizations:** |
| **Past surgical history:** |
| **Social history:** |
| **Developmental Assessment: (include on well child visit only but may be necessary for problem focused notes)** |
| **FAMILY HISTORY** |
| **Mother:** |
| **MGM:** |
| **MGF:** |
| **Father:** |
| **PGM:** |
| **PGF:** |
| |
| **REVIEW OF SYSTEMS** |
| **General:** | **Cardiovascular:** |
| **Skin:** | **Respiratory:** |
| **Eyes:** | **Gastrointestinal:** |
| **Ears:** | **Genitourinary/Gynecological:** |
| **Nose/Mouth/Throat:** | **Musculoskeletal:** |
| **Breast: Heme/Lymph/Endo:** | **Neurological:** |
| | **Psychiatry:** |
| **OBJECTIVE (Document PERTINENT systems only, Minimum 3 for problem focused, all systems for well child exam)** |
| **Weight: Height: BMI: BP: Temp: Pulse: Resp:**<br>**(Insert plotted growth chart below on all well child soap notes)** |
| **General appearance:** |
| **Skin:** |
| **HEENT:** |
| **Cardiovascular:** |
| **Respiratory:** |
| **Gastrointestinal:** |
| **Genitourinary:** |
| **Musculoskeletal:** |
| **Neurological:** |
| **Psychiatric:** |
| **Labs performed in office the day of visit:** |
| |
| **Diagnosis (must complete this section and explain how all differential diagnoses were ruled in or ruled out)** |
| **Differential diagnoses:**<br>1. Diagnosis, (ICD 10 code and reference):<br>2. Diagnosis, (ICD 10 code and reference):<br>3. Diagnosis (ICD 10 code and reference): | **Diagnosis**(ICD 10 code and reference): |
| **Plan/therapeutics/diagnostics;** |
| **Education provided:** |
| **CPT Code:** |
| **Anticipatory guidance (well child visit only)** |
**References:**
**feedbackfocusedWeek3-pedssoapnotetemplate1.docx**
This file is too large to display. [View in new window](https://www.sweetstudy.com/files/feedbackfocusedweek3-pedssoapnotetemplate1-docx)
– 1
– 2