NR 509 Week 6 Pediatric SOAP Note S: Subjective – Information the patient or patient representative told you O: Objective – Information gathered during the physical examination by inspection
nr 509 week 6 pediatric soap note s subjective – information the patient or patient representative told you o objective – information g
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NR 509 (NR509)
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SOAP Note Template
S: Subjective
Information the patient or patient representative told you
Initials: DR Age: 8 Gender: male
Height Weight BP HR RR Temp SPO2 Pain Allergies
127cm 40.8kg 120/ 100 28 37.2C 96% Medication: none
76 Food: none
Environment: none
History of Present Illness (HPI)
Chief Complaint (CC) “cough” “runny nose” “right ear pain” “tired” “sore throat” CC is a BRIEF statement identifying
Onset 5 days ago why the patient is here - in the
Location Throat, right ear patient’s own words - for instance
"headache", NOT "bad headache for 3
Duration Coughing:Constant with episodes every few minutes; Ear/Throat: constant: 1
days”. Sometimes a patient has more
day
than one complaint. For example: If
Characteristics Cough: gurgly, watery, constant; Throat: sore, painful to swallow; Ear: constant the patient presents with cough and
pain sore throat, identify which is the CC
Aggravating Factors Laying down at night and which may be an associated
Relieving Factors Cough medicine symptom
Treatment Cough medicine
Current Medications: Include dosage, frequency, length of time used and reason for use; also include OTC or homeopathic products.
Medication Length of Time
Dosage Frequency Reason for Use
(Rx, OTC, or Homeopathic) Used
Childrens Multivitamin One gummy Once PO daily Click or tap here supplement
Gummies to enter text.
Cough syrup One spoonful One dose this cough
am
Click or tap here to enter text. Click or tap here to Click or tap here to enter Click or tap here Click or tap here to enter text.
enter text. text. to enter text.
Click or tap here to enter text. Click or tap here to Click or tap here to enter Click or tap here Click or tap here to enter text.
enter text. text. to enter text.
Click or tap here to enter text. Click or tap here to Click or tap here to enter Click or tap here Click or tap here to enter text.
enter text. text. to enter text.
Past Medical History (PMHx) – Includes but not limited to immunization status (note date of last tetanus for all adults), past major illnesses,
, hospitalizations, and surgeries. Depending on the CC, more info may be needed.
Pneumonia 1 year ago-unsure of medication given
Recurrent ear infections at younger age
Frequent colds
Frequent nasal drainage
No surgical history
No prior hospitalizations
Up to date on childhood immunizations
Not up to date on flu vaccination
Attends biannual primary care visits- Last physical: 2 months ago
Attends yearly dental exams
No history of eye exams
Social History (Soc Hx) - Includes but not limited to occupation and major hobbies, family status, tobacco and alcohol use, and any other pertinent
data. Include health promotion such as use seat belts all the time or working smoke detectors in the house.
Lives at home with mother, father, grandmother and grandfather
Household uses English primarily as language; Secondary: Spanish
Father smokes cigars on occasion in the household
Student in the 3rd grade
Enjoys English and computers
Hobbies: playing video games, writing stories
Exercise: Gym class daily, going to park with friends after school and on weekends when nice out
Wants to be a director when he is older with his friend Tony, who will be an actor
Fears: Bad guys in movies
Diet: Dislikes veggies; drinks 7-8 glasses of water a day;
Breakfast: cereal, fruit, waffles, eggs, bacon
Lunch: sandwich, chips, applesauce, pudding
Dinner: chicken, rice, ham, stew
Bowel Regimen: 1-2 bowel movements daily
Family History (Fam Hx) - Includes but not limited to illnesses with possible genetic predisposition, contagious or chronic illnesses. Reason for
death of any deceased first degree relatives should be included. Include parents, grandparents, siblings, and children. Include grandchildren if
pertinent.
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