Always chart the following in the Subjective part of the SOAP on a sick visit under Associated Manifestations: = Eating
24 hr. diet recall with amts. fluid intake with specific amts.
how is it? changes? Indicate if no changes
say what it is/are? changes? Indicate if no changes
If caretaker does not know, ask questions to determine if they know how ill the child has been.
TYPES OF PEDIATRIC VISITS: It is often helpful to approach patient evaluation by first deciding what type of visit this is likely to be. Note the possible approaches to a "well child visit" versus an "acute child visit". WELL CHILD VISIT
The goal of the visit is healthmaintenance and anticipatoryguidance: information the parent will need between now and the next visit. It is assumed a data base (Birth hx., PMH, FH, Family/ Household composition is part of the record or Problem List). S.
Appearance. Percentiles for ht., wt., H.C.
Blood pressure (> 3yrs) Complete age-appropriate PE
1) Health Maintenance
1)Immunizations given Safety counseling for age Nutrition counseling Anticipatory guidance Follow-up for next visit with reason if
Follow-up Visit: Should pick up where the previous visit left Off S.PP: Follow-up visit for . Interval Hx. (brief) Were treatment suggestions followed? Was medication taken as prescribed? If patient is worse or the same, more history may be needed.
Determine the presence of any new S or Sym. O. P.E. sufficient to evaluate progress
c:\wpdoc\clininfo\Cl. Supp Info Spring 06 6617 ACUTE VISIT Focus is on the problemwith which the patient presents. S.PP: problem HPI: history of present problem, for each symptom or problem: -Location -Duration -Severity -Timing -Setting -Allev/exacer factors -Associated S&S/behaviors [see list for items for Sick Child Visit] -Current medications -Allergies PMH: major illness/hosp. O.Appearance VS P.E.: with special attention to areas suggested by hx. 1) Health Maintenance* 2) Acute self-limited problem* with codes & Diff. Dx.s with codes for each
*On the traditional problem list (1) is reserved for Health Maintenance and (2) is reserved for acute self-limited problems. P. 1) List and discuss all items related to Health Maintenance and anticipatory guidance which are age appropriate 2) For each numbered diagnosis: Dx: Diagnostic tests Tx: Treatment Ed: Counseling re: Rx/adverse effects Follow-up: RTC/call back; as indicated; if problem is resolved set next appt. according to Health Maintenance Schedule Guidelines for writing the Pediatric SOAP note. NURS 6619 Spring 2007
For this assignment, please choose an episodic, problem focused visit that you
participated in at your clinical site. Remember that this is not a full H&P, but should be
written as a note that you would use to document this patient’s visit with you. The
typical format for a SOAP note is basic and very commonly used in many settings that
you will encounter. Even in circumstances where clinical settings utilize electronic
medical records, it is common for providers to enter a note using the SOAP format. For
an established patient, you would of course already have a more complete H&P in the
patient’s chart. If not, you would be expected to gather the information to assure that
there is a thorough history there for the future and would update it to keep it current with
Subjective
Keep it brief, using patient's or parents words if possible, break it up as follows:
Cc: (chief complaint in patient’s or parents own words)
Please list what is on your differential diagnosis list pertaining to the chief complaint. List these in order of suspicion, #1 being the diagnosis you suspect the most and so on. This list is not all inclusive, meaning what you have here should include only the possibilities that are most probable for this patient based on the data you are gathering. Medical Hx: birth Hx is important in the initial H&P but rarely afterward on episodic visits. Would be important to list recent illnesses and past infections and dates of these, especially when evaluating a child with a recurrent OM or strep infection. Include current prescribed and OTC meds with dosages and drug allergies. (remember to ask about drug allergies at every visit regardless of what you have in front of you. A trip to the ER with an allergic reaction can easily go undocumented) Social Hx: discuss the child’s environment and applicable factors such as whether the child attends day care, do parents smoke around the child, bedtime routines, primary caregiver in home etc. Family Hx: as pertinent, remember there should be a more complete H&P that you
can refer to on the chart, but if say a sibling has been ill at home with similar symptoms then you’d want it in you note.
ROS: this is an abbreviated ROS, meaning that it only pertains to your chief complaint. For example, in the child with a complaint of sore throat, you are going to review systems that relate to that complaint (HEENT, respiratory, maybe cardiac and GI in relation to appetite and fluid intake), but not necessarily systems that are not relative such as neuro or musculoskeletal. Chart only the pertinent positives and pertinent negatives related to your chief complaint. Pertinent positives are reported symptoms that would support a diagnosis on your differential, pertinent negatives would rule out a diagnosis on the differential. Objective Weight, and change from previous weight noting percentiles from growth chart Vitals I&O's PE Labs Assessment, to include your working diagnosis and any “rule outs” you are working on in your differential Plan, includes parental advice, anticipatory guidance and follow-up plan. If you provide written handouts or other resources for parenting or support, list these in your plan.
In your plan, please briefly tell us what the rationale is for how you treated this patient and list any references that you utilized for the assignment.
We are asking you to include your list of differential diagnoses and rationales with references for the academic purposes of this assignment but of course in clinical, these would not be part of your note. Essentially, other than these two differences, this should reflect a piece of solid documentation that you could have entered into a patient’s chart.
Example of a Good Student SOAP Note
Cc: “My son has a terrible cough.” Differential Diagnoses:
1. Bronchitis 2. Pneumonia 3. Sinusitis 4. Asthma exacerbation 5. Allergic rhinitis
S: 7 7/12-year-old male c/o persistent cough x 4 wks. Child’s mother reports that he has
had a decrease in energy and appetite. He has had trouble sleeping as well. Mother also reports his eyes are blood shot and he has dark circles under eyes. Last night he became diaphoretic and c/o chills, mom did not have a thermometer.
Medical Hx: He has a history of seasonal allergies and asthma. Meds: Albuterol 2 puffs four times daily PRN, has been using the inhaler 4-5 times daily NKDA Social Hx: Lives with both parents in a non-smoking household. No pets in the home. 2
brothers, twins aged 5 who have not had any recent illnesses. Has been out of school for the past four days.
ROS: See above, in addition child reports nasal stuffiness and difficulty sleeping due to
cough. ROS is otherwise noncontributory.
O: BP: 102/58; P: 120; T: 98; Wt: 48.5 lb; Ht: 50.5 in; Peak flow: 150; 02 sat: 97%.
Physical examination reveals a pale and thin child. Per mom’s report he has lost weight (previous weight: 50 lbs).
HEENT: TM’s clear, turbinates are red and swollen with occlusion on the left. Pharynx
is notable for cobble stoning, otherwise clear. +tenderness with palpation of left maxillary sinus. + anterior cervical nodes.
Resp: Chest exam reveals coarse rhonchi that don’t clear w/ coughing. Cardiac: S1S2 without M/R/G Labs: WBC: normal (6.2 k/ul) LYM: normal (2.8% L) MID: normal (0.8% M) GRAN: low (2.7% G) HGB: moderately high (14.7 g/dl) MCV: high (86.9 fl) MCH: high (30.1 pg) X-ray: Sinuses: Mucosal thickening of right and left maxillary sinuses (suggestive of
Chest: Slight focal prominence of markings about the mid upper right lung field
(suggestive of early or resolving pneumonia) and background of hyperinflation and prominence of central markings (suggestive of asthma or bronchitis)
A: Findings suggestive of pneumonia and sinusitis. Additional notable findings include
recent weight loss and possible mild dehydration.
2. Rest and stay home from school until Monday 3/22 3. Encourage liquid and foods 4. Follow up visit in 10 days 5. Rx w/ Augmentin (400 mg bid) and Maxair Autoinhaler (use tid 1 inhalation,
6. Mom instructed to call if fever persists or if worsening of symptoms. Rationale: I chose Augmentin in this patient because of it’s broad Gram negative
coverage against pathogens that are the most likely causes of community acquired pneumonia and sinusitis.
Reference: Gilbert, D. N., Eliopoulos, G., M., Moellering, R., C., Sande, M., A.,
The Sanford Guide to Microbial Therapy (2006). 36th ed.
Scottish Executive Health Department Chief Scientist Office A DOUBLE BLIND PLACEBO CONTROLLED TRIAL OF THE EFFECT OF PERINDOPRIL ON MUSCLE STRENGTH AND PHYSICAL FUNCTION IN OLDER PEOPLE Researchers Most participants adhered to the medication for most Dr D Sumukadas, Dr M D Witham, Professor A D of the time. The medication was well tolerated and Struther
can refer to on the chart, but if say a sibling has been ill at home with similar symptoms then you’d want it in you note.
ROS: this is an abbreviated ROS, meaning that it only pertains to your chief