NURSING > QUESTIONS & ANSWERS > South University - NSG 64355 Pediatric SOAP Note: Complete Version. (All)

South University - NSG 64355 Pediatric SOAP Note: Complete Version.

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South University - NSG 64355 Pediatric SOAP Note NP Student Name: Kayla Stevens Child’s Initials: ks DOB: 04/1/04 Clinical Date: 05/21/19 Age: 13 Place of Born: Douglas, GA Week Soap Project: 05/21/19 Sex: M _X__ F ___ Type of Soap Note: Well child visit ___ Sick visit _X___ SUBJECTIVE Historian: Parent and child Present Concerns/CC: “my toe hurts” 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 patient feeds, clothes, dresses himself attends school, keeps a tidy room. Safety Practices: Uses seat belt, no guns in the home Nutrition: Eats three to four meals a day from a variety of food groups. Drinks about 2 sodas per day Changes in daycare/school/after-school care: NA Sleep: has a regular sleep routine during school months, likes to stay up late at night. Sports/physical activity: Plays baseball in the spring. Developmental History: - Gross and fine motor: Appropriate - Cognitive: Takes honors classes when in school does very well with grades. - Social/Emotional/Communication: has lots of friends that he socializes with regularly. SOCIAL: -Denies cigarettes, drugs, and Alcohol. Sexual History (if appropriate): Not sexually active. HPI: The patient is a 13 yo white male who presents with mother for c/o redness and pain to L great toe. States that they thought it was an ingrown toenail and he was picking at the toe. States he has had a low-grade temperature. Denies any other health concerns at present. Medications: No prescribed or OTC medications. PMH: Allergies: NKDA Chronic Illnesses/Major traumas: None reported Hospitalizations/Surgeries: Circumcision during hospitalization Immunizations: Up-to-date Family Medical History (Identify all immediate family members, their age, & health status) Mother: 44-year-old white female with HTN Father: 48-year- white male with CAD, and HTN. Younger sibling (6, female)- no known health problems Social History (complete the areas listed as appropriate; may omit an area if not appropriate to the client) Current living situation/p-artner/marital status: Lives at home with mother and father and sister. Educational level (as appropriate): out of school for the summer will be going into the 8th grade Occupational history (as appropriate): NA Substance use/abuse (ETOH, tobacco, and marijuana): Denies Firearms in home: No guns in home. Safety status: Uses seat belt, no guns in the home

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