Social History Education level, occupational history, current living situation/partner/marital status, substance use/abuse, ETOH, tobacco, and marijuana. Safety status
Name: | Date: |
Sex: | Age/DOB/Place of Birth: |
SUBJECTIVE | |
Historian:
Present Concerns/CC: Reason given by the patient for seeking medical care “in quotes” |
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Child Profile: (Sexual History (If appropriate); ADLs (age appropriate); Safety Practices; Changes in daycare/school/after-school care; Sports/physical activity; Developmental Hx) | |
HPI: (must include all components) | |
Medications: (List with reason for med ) | |
PMH:
Allergies: Medication Intolerances: Chronic Illnesses/Major traumas: Hospitalizations/Surgeries: Immunizations: |
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Family History ( Please identify all immediate family) | |
Social History Education level, occupational history, current living situation/partner/marital status, substance use/abuse, ETOH, tobacco, and marijuana. Safety status | |
ROS | |
General | Cardiovascular |
Skin | Respiratory |
Pediatric SOAP Note
Eyes | Gastrointestinal | |
Ears | Genitourinary/Gynecological | |
Nose/Mouth/Throat | Musculoskeletal | |
Breast | Neurological | |
Heme/Lymph/Endo | Psychiatric | |
OBJECTIVE (plot height/weight/head circumference along with noting percentiles) Attach growth chart | ||
Weight | Temp | BP |
Height | Pulse | Resp |
General Appearance and parent‐child interaction | ||
Skin | ||
HEENT | ||
Cardiovascular | ||
Respiratory | ||
Gastrointestinal | ||
Breast | ||
Genitourinary |
Musculoskeletal |
Neurological |
Psychiatric |
In-house Lab Tests – document tests (results or pending) |
Pediatric/Adolescent Assessment Tools (Ages & Stages, etc) with results and rationale
For adolescents (HEADSSSVG Assessment) |
Diagnosis |
· Include at least three differential diagnoses with ICD-10 codes. (Includes Primary dx and 2 differentials)
· Document Evidence based Rationale for ROS and each differential with pertinent positives and negatives · Primary diagnosis · Is #1 on list of differentials · Evidence for primary diagnosis should be supported in the Subjective and Objective exams. PLAN including education · Plan: Treatment plan should be for the Primary Diagnosis and based on EB literature. · Include EB rationale for all aspects of your treatment plan: · Vaccines administered this visit · Vaccine administration forms given · Medication-amounts and mg/kg for medications · Laboratory tests ordered · Diagnostic tests ordered · Patient education including preventive care and anticipatory guidance · Non-medication treatments · Follow-up appointment with detailed plan of f/u |
*ALL references must be Evidence Based (EB)