week 4 peds soap note. Well child visitCase: Patient 9 yr old F African American Normal assessment Education: Non-educational electronics use to less than 2 hours per day Sleep at least 8 hrs at night Exercise at least 30 minutes 3 times a week Dentist visit 2 times a year and brush teeth 2 times per day Smoke detectors at home Look both sides when crossing the street Follow-up in 1 year or PRN Z00.129 | Encntr for routine child health exam w/o abnormal findings Subjective, Objective, Assessment, Plan (SOAP) Notes Student name: Course: Patient name (initials only): Date: Time: Ethnicity: Age: Sex: SUBJECTIVE CC: HPI: Medications: Past medical history: Allergies: Birth hx: (use only on well child visits): Immunizations: Hospitalizations: Past surgical history: Social history: Developmental Assessment: (include on well child visit only but may be necessary for problem focused notes) FAMILY HISTORY Mother: MGM: MGF: Father: PGM: PGF: REVIEW OF SYSTEMS General: Cardiovascular: Skin: Respiratory: Eyes: Gastrointestinal: Ears: Genitourinary/Gynecological: Nose/Mouth/Throat: Musculoskeletal: Breast: Heme/Lymph/Endo: Neurological: Psychiatry: OBJECTIVE (Document PERTINENT systems only, Minimum 3 for problem focused, all systems for well child exam) Weight: Height: BMI: BP: Temp: Pulse: Resp: (Insert plotted growth chart below on all well child soap notes) General appearance: Skin: HEENT: Cardiovascular: Respiratory: Gastrointestinal: Genitourinary: Musculoskeletal: Neurological: Psychiatric: Labs performed in office the day of visit: Diagnosis (must complete this section and explain how all differential diagnoses were ruled in or ruled out) Differential diagnoses: 1. Diagnosis, (ICD 10 code and reference): 2. Diagnosis, (ICD 10 code and reference): 3. Diagnosis (ICD 10 code and reference): Diagnosis (ICD 10 code and reference): Plan/therapeutics/diagnostics; Education provided: CPT Code: Anticipatory guidance (well child visit only) References:
Case: Patient 9 yr old F African American Normal assessment Education: Non-educational electronics use to less than 2 hours per day Sleep at least 8 hrs at night Exercise at least 30 minutes 3 times a week Dentist visit 2 times a year and brush teeth 2 times per day Smoke detectors at home Look both sides when crossing the street Follow-up in 1 year or PRN Z00.129 | Encntr for routine child health exam w/o abnormal findings Subjective, Objective, Assessment, Plan (SOAP) Notes Student name: Course: Patient name (initials only): Date: Time: Ethnicity: Age: Sex: SUBJECTIVE CC: HPI: Medications: Past medical history: Allergies: Birth hx: (use only on well child visits): Immunizations: Hospitalizations: Past surgical history: Social history: Developmental Assessment: (include on well child visit only but may be necessary for problem focused notes) FAMILY HISTORY Mother: MGM: MGF: Father: PGM: PGF: REVIEW OF SYSTEMS General: Cardiovascular: Skin: Respiratory: Eyes: Gastrointestinal: Ears: Genitourinary/Gynecological: Nose/Mouth/Throat: Musculoskeletal: Breast: Heme/Lymph/Endo: Neurological: Psychiatry: OBJECTIVE (Document PERTINENT systems only, Minimum 3 for problem focused, all systems for well child exam) Weight: Height: BMI: BP: Temp: Pulse: Resp: (Insert plotted growth chart below on all well child soap notes) General appearance: Skin: HEENT: Cardiovascular: Respiratory: Gastrointestinal: Genitourinary: Musculoskeletal: Neurological: Psychiatric: Labs performed in office the day of visit: Diagnosis (must complete this section and explain how all differential diagnoses were ruled in or ruled out) Differential diagnoses: 1. Diagnosis, (ICD 10 code and reference): 2. Diagnosis, (ICD 10 code and reference): 3. Diagnosis (ICD 10 code and reference): Diagnosis (ICD 10 code and reference): Plan/therapeutics/diagnostics; Education provided: CPT Code: Anticipatory guidance (well child visit only) Case: Patient 9 yr old F African American Normal assessment Education: Non-educational electronics use to less than 2 hours per day Sleep at least 8 hrs at night Exercise at least 30 minutes 3 times a week Dentist visit 2 times a year and brush teeth 2 times per day Smoke detectors at home Look both sides when crossing the street Follow-up in 1 year or PRN Z00.129 | Encntr for routine child health exam w/o abnormal findings Subjective, Objective, Assessment, Plan (SOAP) Notes Student name: Course: Patient name (initials only): Date: Time: Ethnicity: Age: Sex: SUBJECTIVE CC: HPI: Medications: Past medical history: Allergies: Birth hx: (use only on well child visits): Immunizations: Hospitalizations: Past surgical history: Social history: Developmental Assessment: (include on well child visit only but may be necessary for problem focused notes) FAMILY HISTORY Mother: MGM: MGF: Father: PGM: PGF: REVIEW OF SYSTEMS General: Cardiovascular: Skin: Respiratory: Eyes: Gastrointestinal: Ears: Genitourinary/Gynecological: Nose/Mouth/Throat: Musculoskeletal: Breast: Heme/Lymph/Endo: Neurological: Psychiatry: OBJECTIVE (Document PERTINENT systems only, Minimum 3 for problem focused, all systems for well child exam) Weight: Height: BMI: BP: Temp: Pulse: Resp: Read More …