SU NSG6 435 Stevens K doc Week 9 Soap Note 1

Child Profile: (complete the areas listed as appropriate; may omit an area if not appropriate to the client) Activities of Daily Living (age appropriate): The child dresses independently but does sometimes need help mat ...

Child Profile: (complete the areas listed as appropriate; may omit an area if not appropriate to the client) Activities of Daily Living (age appropriate): The child dresses independently but does sometimes need help matching outfits. The child brushes teeth independently at least twice per day. The child is learning to tie shoes but does require help. The child settles for sleep independently. The child sleeps in her own bed. The child feeds self without difficulty. Safety Practices: Home is childproofed with covers on electrical outlets, uses booster seat, able to swim, mother states sunscreen is used, -tobacco/ETOH abuse, -falls, -lead, - TB exposure Nutrition: Mother states that the child drinks 2% milk at least one cup daily. Mother states the child does drink juices and koolaids. States that she attempts to ensure that the child drinks as much water as possible. States the child’s taste in food changes from day to day, but she does try to ensure that she east plenty of fruits and vegetables. Changes in daycare/school/after-school care: Stays at home with mother during the day while father works. Will be attending kindergarten in the fall. Sleep: The child sleeps in her bed at night and usually goes to sleep around 9 pm and wakes up at 8 am. Mother reports child sleeps through the night. Does take one nap per day. Sports/physical activity: NA Developmental History: - Gross motor: Hops, Skips, rides bicycle with training wheels, swims with no floaties. - Fine motor: uses scissors, colors in the lines, can draw simple objects, manages buttons and zippers - Cognitive: Follows simple directions, can draw shapes, knows colors, knows alphabet - Social/Emotional: plays well with other children, able to follow the rules of games such as “Simon Says”. - Communication: Has a large vocabulary. Clearly and easily understood. Sexual History (if appropriate):NA