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PRAC 6541 Episodic/Focused SOAP Note Template; RR, a one-month-old female

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PRAC 6541

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PRAC 6541

HPI: RR, a one-month-old female Caucasian patient, was brought in by her mother for a routine checkup. Concerns arose regarding a sudden rash on RR's face, which began approximately one week ago. Her mother stated that there had been no changes in RR's diet, skincare products, or detergents. RR is ...

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prac 6541 episodicfocused soap note template rr

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PRAC 6541: Primary Care of Adolescents and Children

Episodic/Focused SOAP Note Template

Patient Information:

RR, 0 years, 1 month, F, Cauc.

S.

CC: “Routine checkup and rash on her face.”

HPI: RR, a one-month-old female Caucasian patient, was brought in by her mother for a
routine checkup. Concerns arose regarding a sudden rash on RR's face, which began
approximately one week ago. Her mother stated that there had been no changes in
RR's diet, skincare products, or detergents. RR is exclusively breastfed, and her mother
confirmed that her own diet had not deviated from the norm. The rash tends to clear up
towards the end of the day but is more prominent during daytime hours. While RR does
not seem bothered by the rash, her mother sought advice on potential management.
There are no apparent aggravating factors, and no specific treatment has been initiated.
RR's mother expressed concern and is seeking guidance on how to address the rash,
prompting her visit to the clinic.

Current Medications: None reported by patient’s mother.

Allergies: NKDA, no environmental, seasonal, or latex allergies reported by mother.

PMHx: None reported by patient’s mother.

Soc & Substance Hx: RR, a one-month-old female Caucasian patient, was brought in
by her mother, Amanda, for a routine checkup. Amanda is a stay-at-home mom who
enjoys gardening and cooking in her free time. She is married to RR's father, Randall,
who serves in the military, and they live together with RR in Fredericksburg, Virginia.
Amanda reports no tobacco or alcohol use, either currently or in the past. The family
ensures that seat belts are used at all times while driving, and they have working smoke
detectors installed throughout their home. Their living environment is clean and well-
maintained. Amanda refrains from using her cell phone while driving to prioritize safety.
The family has a strong support system in place, with close relatives and friends
available for assistance when needed.

Fam Hx: Mother 30 y/o healthy, Father 31 y/o healthy. Maternal and paternal family
history is not available due to limited patient information or patient's inability to provide
this data at the time of the visit. Patient's medical history is solely based on current
symptoms and clinical evaluation.

Surgical Hx: None reported by the patient’s mother.

1

, PRAC 6541: Primary Care of Adolescents and Children

Mental Hx: The mother reports that the baby has been generally content and does not
seem to be experiencing any unusual fussiness or difficulty sleeping at this time.

Violence Hx: None reported by patient’s mother. Patients mother reports using a rear
facing car seat and the house has baby proof to assure the safety of her child.

Reproductive Hx: Breastfeeding by patient mother. The mother reports no concerns
developmentally.

ROS:

GENERAL: Mother reports no weight loss, fever, acting differently, or fussiness.

HEENT: Eyes: Mother reports no eye drainage or yellow sclerae. Ears, Mother reports
no ear drainage, trauma, or infant fussing. Nose, Mother reports no drainage, bleeding,
trauma, or congestion. Throat: Mother reports no screaming, fussiness, trouble feeding,
spiting up, or drooling.

SKIN: Reports rash on patients face.

CARDIOVASCULAR: Reports no cardiac history, discoloration while feeding, swelling,
or sleeping excessively.

RESPIRATORY: Mother reports no shortness of breath, cough, congestion, or sputum.

GASTROINTESTINAL: Mother reports no trouble eating, nausea, vomiting, or diarrhea.
No abdominal tightness or blood.

GENITOURINARY: Mother reports plenty of wet diapers with no discoloration or foul-
smelling urine.

NEUROLOGICAL: Mother reports no extra fussiness, change in sleeping patterns or no
change in bowel or bladder control.

MUSCULOSKELETAL: Mother reports no abnormalities in movement or posture, such
as asymmetry, stiffness, or unusual positioning of limbs.

HEMATOLOGIC: Mother reports no anemia, bleeding, or bruising.

LYMPHATICS: Mother reports no lymph nodes in areas such as the neck, armpits, and
groin for any enlargement or tenderness.

PSYCHIATRIC: Mother reports no unusual crying patterns, feeding difficulties, or sleep
disturbances.

ENDOCRINOLOGIC: Mother reports no lethargy or poor feeding.

2

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