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NSG 6435 Comprehensive SOAP Note Tommy Acker V5
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NSG 6435 Comprehensive SOAP Note Tommy Acker V5
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NSG 6435 Comprehensive SOAP Note Tommy Acker V5Pediatric SOAP Note
NP Student Name: Kayla Stevens Child’s Initials: CC DOB: 01/02/2019
Clinical Date: 06/25/19 Age: 6 months Place of Born: Douglas, GA
Sex: Type of Soap Note:
Week Soap Project: 6/25/19 M _X Well child visit X
F Sick visit
SUBJECTIVE
Historian: Parent
Present Concerns/CC: ROTA, HIB LT, Pedi-rex LT, Prevnar 13-RT"he has to have shots today"
Child Profile: (complete the areas listed as appropriate; may omit an area if not appropriate to the client)
Activities of Daily Living (age appropriate): NA
Safety Practices: Parents are using car seat, have not had infant around large crowds, infant sleeps on back in crib, does
practice safety as infant can roll over now, smoke and carbon monoxide detector in home, child safety locks on cabinets
Nutrition: Drinks 6oz of Similac advanced every 4 hours. Eats babyfood and tablefood. Does not drink juice. Changes
in daycare/school/after-school care: NA
Sleep: Has a regular bedtime routine, and sleeps through the night without
feeding. Sports/physical activity: NA
Developmental History:
- Gross and fine motor: Head flexed forward when pulled to a sitting position. Is able to sit up, rolls over both ways.
Reaches and grabs; raking grasps.
- Cognitive: Responds to affection. Turns towards sounds.
- Social/Emotional/Communication: Smiles, laughs, likes to talk and
play. SOCIAL:
- No smokers in the home.
- No concerns regarding postpartum depression.
- No major social stressors at home.
- No safety concerns in the home.
Sexual History (if appropriate):NA
HPI:
S: The patient is a 6 month old white male who presents with mother for well examination.The infant is reaching for objects,
babbling, sitting up, and crawling. Drinks 6oz of Similac advanced every 4 hours. Eats babyfood and tablefood. Does not drink
juice. Denies TB or lead exposure. Denies any health concerns at present.
Medications:
No prescribed or OTC medications.
T
Revised 5/9/18; 8/9/18; 10/29/18
https://www.coursehero.com/file/43415083/62519-soap-notedocx/
, NSG 6435 Comprehensive SOAP Note Tommy Acker V5
PMH:
Allergies: NKDA
Chronic Illnesses/Major traumas: None reported
Hospitalizations/Surgeries: Circumcision during hospitalization
Immunizations: Up-to-date
his study source was downloaded by 100000815611969 from CourseHero.com on 11-09-2022 23:18:01 GMT -06:00
T
Revised 5/9/18; 8/9/18; 10/29/18
https://www.coursehero.com/file/43415083/62519-soap-notedocx/
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