Infectious diseases (not related to vaccines), genetic disorders or pain management.
- Make sure that you're using appropriate PEDIATRIC questions for the HPI/ROS/Hx and appropriate exam findings. For example, you would not ask whether or not the patient is experiencing chest pain/dizziness for a 4 month-old-infant.
- ALL SOAP notes should include basic biological functioning assessment, growth curves and percentiles with vital signs, etc…. A well visit SOAP does not need differential diagnoses, but rather a detailed, comprehensive documentation.
- SOAP notes must be detailed and include at least 3 differential diagnoses related to the final diagnosis. Make sure you know the difference between "actual" and "differential" diagnoses.
- Current clinical guidelines need to be included/cited with all SOAP notes. If the plan of care did not follow the current guideline, then you need to discuss why when you reflect on the visit. References and intext citations must be in complete APA format.
- When you prescribe a medication, then include the dose recommendation, the strength of the medication, frequency, route, amount to be dispensed and refills. This process will help you learn how to write a prescription, which is very important in pediatrics since most medications are weight based. An example: For strep pharyngitis the recommended antibiotic is amoxicillin @ 50 mg/kg/day divided q12hr. Child's weight = 17 kg = 850 mg/day. Amoxicillin's strength = 400 mg/5 mL. Therefore the child is to take 5 mL po q12 hr x 10 days. Dispense 100 mL with 0 refills.
- Make sure to keep the SUBJECTIVE data (what the family/patient tells you) separate from your OBJECTIVE data (what you see, feel, hear, measure, etc..).
- These SOAP notes will be graded using the grading rubric provided with each weekly assignment. For more details of the elements of a great SOAP note, please see the document saved in Doc Sharing entitled Elements of a Great SOAP Note.
Remember to due self assessments on each SOAP subject
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Explanation & Answer
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Pediatric SOAP Note
Common Cold SOAP
Name: KATHY JOBS
Date: 28th 0CT 2017
Age: 2 yrs.
DOB: 20th OCT 2015
Place of Birth: San Diego
Historian: The mother
“My daughter has been sneezing and a runny nose for the past three days.”
“The child has appears fatigued.”
“She is frequently sneezing.”
“Her temperatures seem to be slightly higher.”
“She has a rush under the diaper.”
“ her appetite is decreasing”
K.J. is a 2-year-old white girl, who according to the report given by the mother, has been
well socially before the symptoms that the mother talks about manifest within the baby. The
diet of the child is made up eggs, fruits, food high in iron, vegetables, and cereals. The
mother says that that child’s appetite has been good until the period when the symptoms
started manifesting. The mother says that the child is not allergic. K. J sleeps at 8 PM and
wakes up at 7 AM with normal sleeping hours with normal sleeping patterns. The child’s
development at the pre-school is normal with a good relationship with the caregivers
according to the mum. Some of the safety measures that the mother has put in place include
`keeping sharp objects away from the baby, keeping hot objects covered or beyond the reach
of the child, ensuring that there are firefighting and fire detectors within the house. The
development of the child is quite well reflecting the age stated by the mother
Pediatric SOAP Note
HPI: (must include all components)
The mother of the kid states that the kid has had slightly higher oral temperatures which have
increased over the last 24 hours. The mother claims that the child has also been sneezing lately which
mostly takes place throughout the day as opposed to sneezing at either morning or evening. According
to the mother, a rash can be noted below the diaper with the baby appearing weak. The mother says that
the bay does not seem to have any visual problems, but she has had a runny nose for the past three
Flonase to curb sneezing and runny nose
Allergies: no allergies
Medication Intolerances: no medical
Chronic Illnesses/Major traumas: the child does not suffer any major
traumas or illnesses
Hospitalizations/Surgeries: the has nor any record of surgeries or
hepatitis A shot vaccine
Family History (Please identify all immediate family)
The patient lives with her mother and dad together with one sibling. The maternal grandfather
succumbed a year ago at 65 due to liver cirrhosis, the maternal grandmother is alive but struggling ...