NSG 64355 Pediatric SOAP Note: Complete Version | South University
NP Student Name: Kayla Stevens Child’s Initials: CC DOB: 01/02/2019
Clinical Date: 06/25/19 Age: 6 months Place of Born: Douglas, GA
Week Soap Projec
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NSG 64355 Pediatric SOAP Note: Complete Version | South University
NP Student Name: Kayla Stevens Child’s Initials: CC DOB: 01/02/2019
Clinical Date: 06/25/19 Age: 6 months Place of Born: Douglas, GA
Week Soap Project: 6/25/19 Sex:
M _X__
F ___ Type of Soap Note:
Well child visit __X__
Sick visit ____
SUBJECTIVE
Historian: Parent
Present Concerns/CC: ROTA, HIB LT, Pedi-rex LT, Prevnar 13-RT"he has to have shots today"
Child Profile: (complete the areas listed as appropriate; may omit an area if not appropriate to the client)
Activities of Daily Living (age appropriate): NA
Safety Practices: Parents are using car seat, have not had infant around large crowds, infant sleeps on back in crib, does practice safety as infant can roll over now, smoke and carbon monoxide detector in home, child safety locks on cabinets
Nutrition: Drinks 6oz of Similac advanced every 4 hours. Eats babyfood and tablefood. Does not drink juice. Changes in daycare/school/after-school care: NA
Sleep: Has a regular bedtime routine, and sleeps through the night without feeding.
Sports/physical activity: NA
Developmental History:
- Gross and fine motor: Head flexed forward when pulled to a sitting position. Is able to sit up, rolls over both ways. Reaches and grabs; raking grasps.
- Cognitive: Responds to affection. Turns towards sounds.
- Social/Emotional/Communication: Smiles, laughs, likes to talk and play.
SOCIAL:
- No smokers in the home.
- No concerns regarding postpartum depression.
- No major social stressors at home.
- No safety concerns in the home.
Sexual History (if appropriate):NA
HPI:
S: The patient is a 6 month old white male who presents with mother for well examination.The infant is reaching for objects, babbling, sitting up, and crawling. Drinks 6oz of Similac advanced every 4 hours. Eats babyfood and tablefood. Does not drink juice. Denies TB or lead exposure. Denies any 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: 32-year-old white female with no known health problems.
Father: 40-year- white male with 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. This is their first child.
Educational level (as appropriate): NA
Occupational history (as appropriate): NA
Substance use/abuse (ETOH, tobacco, and marijuana): NA
Firearms in home: No guns in home.
Safety status: Parents are using car seat, have not had infant around large crowds, infant sleeps on back in crib, does practice safety as infant can roll over now, smoke and carbon monoxide detector in home, child safety locks on cabinets
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