Week 3 child wellness SOAP Note

· Write an entire SOAP for the well child visit that took place during immersion. For the child, please use the history you obtained during your encounter. For the chief complaint of all notes, you will write “well visit.” See MSN 572 week 1 content for more information on SOAP note writing. Please use your AAP Bright Future’s guide as the main resource for this assignment. Note that pediatrics will require more information than most SOAP notes, including percentiles for Ht/Wt/BMI, and developmental history, among other differences.

· Please plot the height, weight, and BMI for your child on a growth chart (samples can be found on CDC) and include the growth chart with your submission.

· Make sure you include a developmental assessment, and for pre-teens and teens, a HEEADSSS assessment.

· Preferably, use the format described at immersion by using one of the templates in week one of the course. Make sure to include an assessment (diagnosis) and plan. Do not perform a risk assessment but use actual diagnosis terminology. Be sure to use APA format and include references. Review the rubric before you begin working on the assignment.

Criteria

Exceeds Expectations

Meets Expectations

Below Expectations

Far Below Standard

Identifying Data

5 points

Correctly lists all components of the Identifying data including initials, age, DOB, gender, race, ethnicity and whether they came to clinic alone or accompanied and if they are a reliable historian.

4 points

Missing one of the elements, or not written in a complete/logical sentence.

2 points

Missing 2 or more items.

0 points

Not included or written in the wrong area (only in HPI instead of separately).

Chief Complaint

5 points

Listed the chief complaint in patient’s own words with quotation marks “complaint”. CC is brief and not over a sentence long.

4 points

Missing one element (not in quotations, not in patients own words, etc).

2 points

Incomplete not in the patient’s own words.

0 points

Not Included

History of present illness

15 points

HPI written succinctly in paragraph format. If patient has no complaints (such as a wellness visit), the student summarizes the past health history including mo/year of last physical and any pertinent health maintenance or recent lab work.

For problem visits, the HPI narrates a story of the patient’s problem. If there is a complaint, all elements of HPI are addressed (OLDCARTs or OPQRST) as appropriate for complaint.

13 points

Most elements addressed, missing one or two items, but not missing an item that would severely change the treatment of patient.

10 points

For any complaint, missing 3 or more of the 7 HPI elements. Or for an annual exam, missing health maintenance history or summary of patient’s overall health. Missing an item that would alter the treatment.

7 points

<5 variables identified, or not included. May give a zero if not included. Did not provide a synopsis of the patient’s problem or health status.

Past Medical History

15 points

All elements of PMH are described, including medical problem list, surgical history with mo./year of procedure or hospitalization, allergies to environment, food, and drugs, list of meds with doses, and any chemical history (alcohol, drugs, tobacco, caffeine), immunization status. LMP must be included for women of child bearing age. For problem visit, the medical history is pertinent to th

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Well Child Soap

USU

Physical Assessment MSN 572

January 10, 2021

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Well Child Soap

SUBJECTIVE:

ID: Manon is a 13-year-old female who came to the clinic for her annual wellness check. She is

not an established patient. She is in 8th grade and currently resides with her mother, father, and

siblings. Manon states she has not had a wellness check in a while. She has no complaints

currently.

Pt. M., DOB11/01/07, Age 13-year-old, African American identifies as female, arrived with

parents to the clinic but unaccompanied by parents during interview is a reliable source of

information.

CC: “I am here for my wellness exam”

HISTORY OF PRESENT ILLNESS (HPI): 13-year-old female is here for her wellness exam and

states she feels well and healthy. She does not recall when her last exam was. She is up to date on

her immunizations a flu shot. Denies any medication use apart from allergy medicine prn and an

expired Epi pen for emergency use r/t peanut allergy. She last saw her dentist July 2020 for

braces removal. She denies any complaints or concerns at this time. Patient presents as a reliable

historian.

PAST MEDICAL HISTORY: M. is a 13-year-old African American female who presented to

clinic for her routine wellness exam. Generally, she feels healthy. She was visiting the dentist

monthly until last July as she had her braces removed. She has a difficult time with her retainer

often forgetting to remove it prior to eating. Patient verbalizes that she is “pretty healthy.” Patient

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stated that she broke her R. clavicle at 2.5 years old due to jumping on the bed. No implications

post injury. Patient denies surgery. Pt. Verbalizes that she has had one episode of Swimmer’s ear

treated with antibiotics with which she cannot remember the name of at this time. Pt. Has been

treated for Eczema at the age of 9 which as treated topical creams and has since resolved.

PAST MEDICAL PROCEDURES: Patient denies surgeries or hospitalizations.

MEDICATIONS: Takes over the counter seasonal allergy medication (Claritin 10mg po once

daily prn) and carries an expired Epi pen in the event of an anaphylactic shock due to an allergic

reaction. Patient knowledgeable on how to utilize an Epi pen. Educated on obtaining a new Epi

pen that is not expired. Patient states taking antibiotics a long time ago for Swimmer’s ear. She

takes fish oil for omega-3 daily. Denies any additional vitamins or supplements.

ALLERGIES: Patient has severe allergy to peanuts as evidenced by shortness of breath,

wheezing, hives, and anaphylactic reaction.