SOAP Note 1-12 Year Old

SOAP Note 1-12-Year-Old: Wellness Visit for a child aged 1-12 years old including specific vitals and measurements…

Requirements:

3 APA references within the last 5 years

United States University

Student name

FNP 592: Common Illnesses Across the Lifespan

Instructor

Date

SOAP

SUBJECTIVE:

ID:

CC:

HISTORY OF PRESENT ILLNESS (HPI):

PAST MEDICAL HISTORY:

PAST MEDICAL PROCEDURES:

MEDICATIONS:

ALLERGIES:

FAMILY HISTORY:

Mom:

Dad:

Brother:

Sister:

Paternal grandpa:

Paternal grandma:

Maternal grandpa:

Maternal grandma:

SOCIAL HISTORY:

-SEXUAL/REPRODUCTIVE:

-TOBACCO USE/Vaping:

-ALCOHOL USE:

-DRUG USE:

-MARITAL HISTORY:

-OCCUPATION:

-EXERCISE/DIET:

-SLEEP/STRESS:

-HOUSING:

-SAFETY:

IMMUNIZATIONS:

SPIRITUAL:

SUICIDE/DEPRESSION:

ROS:

CONSTITUTIONAL:

INTEGUMENTARY:

HEAD, EYES, EARS, NOSE, THROAT:

RESPIRATORY:

NECK:

CARDIOVASCULAR:

GASTROINTESTINAL:

PERIPHERAL VASCULAR:

GENITOURINARY:

MUSCULOSKELETAL:

PSYCH:

NEURO:

HEMATOLOGIC:

ENDOCRINE:

ALLERGY/IMMUNOLOGY:

OBJECTIVE:

VITAL SIGNS:

P: BP: RR: T: SpO2 RA: Pain:

Ht: Wt: BMI:

/

PHYSICAL EXAM:

GENERAL survey:

HEENT:

NECK:

CHEST/BREAST:

RESPIRATORY:

CARDIOVASCULAR:

ABDOMEN/GI:

GASTROURINARY:

LYMPHATIC:

MUSCULOSKELETAL:

NEUROLOGIC:

PSYCHIATRIC:

SKIN:

PERIPHERAL VASCULAR:

ASSESSMENT:

1.

2.

3.

Final diagnosis:

PLAN:

Diagnostic labs:

Treatment/Therapeutic Plan (meds):

Education & F/U plan:

Referrals:

References

1.

2.

3

See also  Assessment and Care Management for Dementia Patients.

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