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_
...
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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