- 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.” 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.
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Criteria |
Exceeds Expectations |
Meets Expectations |
Below Expectations |
Far Below Standard |
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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). |
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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 |
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History of present illness |
15 points HPI written succinctly in paragraph format. If the 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. |
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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 t · 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.” 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. Use actual diagnosis terminology. Be sure to use APA format and include references. Review the rubric before you begin working on the assignment. RB is a 7yr old pt. who presents to the clinic for a routine well child checkup visit with his parents. He is not an established patient. Today he weighs 51.8 lbs and is 122cm tall, as measured in the clinic. BP: 94/60 P:80 RR:20 T: 98.4F DOB: 9/18/14 Last check up: LAST YEAR No hospitalization/surgery No past hx No medication No allergies other than peanuts, asking for refill of epipen Has pets: 1 dog Eats fruits and vegetables “eats very good” as per mother. Likes candies No concerns with developments 1st grade, very sociable, makes friends, plays baseball. No bullying Flu Shot January Siblings: 13, 5, 6, 1 years old: no health problems noted Last Dental Appointment: March Last Eye Appointment: January RB plays with siblings, helps with chores, very independent, little bossy, sleeps well, balance with outside games Safety Dad lives with them. Stay at home mom No guns, no relocation, booster seat, buckle up for safety Bicycle Swimming pool, lifeguard watching Lives in a 50-year-old house—screen for lead and asbestos Grandparents: cancer, hypertension, diabetes No smoking no etoh and recreational drugs >Calculate the height and weight percentiles, BMI and BMi percentile using an app or website. >Is there an immunization record? If so, check it against the immunization schedule (CDC) are any due? Diagnosis: 1. encounter for well child exam 2. encounter for immunization 3. Allergy to peanuts >>Offer education about immunization >>prescribe epipen for allergy to peanuts >>Subjective: Add CDC immunization schedule applicable to patient. >>Objective: Plot Growth Chart < STUDENTS: When using this template, erase all items in blue and in parenthesis. This is only one of hundreds of templates available. This is an academic SOAP note. In clinic, the note format will be dictated by the organization’s EMR. Nonetheless, all the information is present, and it is still a SOAP note. ERASE ALL THE FORMATTING IN BLUE – THEY ARE DIRECTIONS Subjective ID: Include info such as initials, DOB and age, race, gender, whether the patient is a reliable source, and how they came to the clinic (alone/ accompanied by spouse, etc.) Some clinicians write a statement about their overall reliability as a historian/recorder of their information. To protect confidentiality, please use a made up DOB and initials. CC: ALWAYS in patient’s own words. Use quotations. Example: CC: “I’m here for a cough” or “annual check up” or “my throat hurts”
HPI Write this out in “OLDCARTS” Onset/timing Location Duration Context/Setting & Characteristics (i.e. Quality) Aggravating factors and Associated Symptoms Relieving factors Treatments tried/Modifying Factors Severity Example: HPI : Jillian X, a 63 year old white Jewish female, is here for her annual wellness visit. She states that she is in overall average physical health and her last physical was mo/d/2018. Her last mammogram was x/xx/20xx and last pap smear was x/xx/20xx, both normal. Jillian has had most normal health screenings as advised, and her last cholesterol levels were done on x/x/20xx and normal. She admits she has never had a colonoscopy. Her current complaint list includes a runny nose and ear pain that began 3 weeks ago (8/19/2019) and occurs intermittently. She has used aloe vera homemade remedy and feels relieved from her remedy within in 20 min. The symptoms were not so severe as to cause her to seek treatment (those she report ear ache as 8-9/10) but she felt she was able to handle them at home. She has no other complaints at this time. If they are seeing you for a well exam, and have no complaints identified later in the ROS, then write up why they are here, the date of their last physical, any concerns they have, and also write up mo/year of last screening tests. There is an example in week 1 powerpoint lecture.
Medical Problem list:(diabetes, asthma, HTN, etc) Surgeries and hospitalizations (include Immunizations: (including annual flu vaccine, for older people PNA and shingles vaccine) Allergies: (food, dru 
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