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”

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:

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 parentchild 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)

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