References must be less than 5 years old, provide 5 references at least

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Pediatric SOAP Note Assignment

Directions:

This Assignment will demonstrate your ability to integrate the psychosocial needs of the child and the family into the plan of care in a culturally sensitive and family-focused manner. You are assigned to complete exercise # 4 on the attach file from the cases in your Study Guide to Accompany Advanced Pediatric Assessment on pages 32–33. You may add appropriate information for the child in order to complete the SOAP note template which should include, but not limited to, vital signs, height and weight, ROS, and physical exam results. All the information presented in the case study must be applied to your SOAP note.

For ease of learning, a SOAP note template has been provided. For this Assignment, proper citation and referencing is required because this is an academic paper.

See attach file

ASSIGNMENT PEDIATRIC SOAP NOTE

SUBJECTIVE

Chief Complaint (CC):

History of Present Illness (HPI):

Last Menstrual Period (LMP — if applicable):

Allergies:

Past Medical History:

Family History:

Surgery History:

Social History:

Current medications:

Review of Systems (ROS)

Constitutional:

HEENT:

Cardiovascular:

Respiratory:

Gastrointestinal:

Genitourinary:

Musculoskeletal:

Psychiatric:

OBJECTIVE

Vital Signs/Height/Weight/BMI/Percentiles:

General Appearance:

HEENT:

Neck:

Cardiovascular:

Respiratory:

Abdomen:

Genitourinary:

Extremities:

Back/Hips:

Musculoskeletal:

Dermatologic:

Psychiatric:

Neurological:

ASSESSMENT

A: Differential diagnoses with cited rationale (list at least 3)

1.

2.

3.

B: Medical diagnosis with cited rationale (list at least 1)

1.

PLAN

Orders (replace text in 1–5 below with your content)

1. Prescriptions with dosage, route, directions to administer, amount to be dispensed, and any refills
2. Diagnostic testing
3. Problem-oriented education
4. Health promotion/maintenance needs/psychosocial needs
5. Referrals

Patient/Family Education:

Cultural Considerations:

Follow-Up Plans (replace text in 1–3 below with your content)

1. Return to clinic (RTC) in what time frame and reason for next visit
2. Interventions considered if not improved
3. Next health maintenance visit due

References

Author, A. B., & Author, C. D. (year). Title of reference. Where located. This is the basic formula for all reference entries. The following are some examples.

Able, E. F., Cain, J. K., & Daniels, L. M. (year). Title of webpage/article, if article. Retrieved from URL [Note, no period at end of this kind of entry]

Boyer, R. M. (year). Title of journal article. Title of Journal, volume number, (issue number), pages numbers of article.

Elephant, N. O. (year). Title of chapter. In P. Q. Frank & R. S. Grant (Eds. [if listed as editor on book; leave off if not]), Title of book here (3rd ed. [if edition number present], pp. XX–YY). City, STATE ABBREVIATION: Jones and Bartlett [Note, no “Publisher” or other words used].

Higgs, T. U. (year). Title of book (edition number, if one, as: xth ed.). City, STATE: Publisher.

Johnson, X. Y. (year, month day). Title of video [Video file]. Retrieved from URL

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