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:
(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:
(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:v
References:
References:
