Expert answer:SOAP note
Solved by verified expert:Infectious diseases (not related to vaccines), genetic disorders or pain
management. Make sure that you’re using appropriate PEDIATRIC questions for the HPI/ROS/Hx and appropriate exam findings. For example, you would not ask whether or not the patient is experiencing chest pain/dizziness for a 4 month-old-infant. ALL SOAP notes should include basic biological functioning assessment, growth curves and percentiles with vital signs, etc…. A well visit SOAP does not need differential diagnoses, but rather a detailed, comprehensive documentation. SOAP notes must be detailed and include at least 3 differential diagnoses related to the final diagnosis. Make sure you know the difference between “actual” and “differential” diagnoses. Current clinical guidelines need to be included/cited with all SOAP notes. If the plan of care did not follow the current guideline, then you need to discuss why when you reflect on the visit. References and intext citations must be in complete APA format. When you prescribe a medication, then include the dose recommendation, the strength of the medication, frequency, route, amount to be dispensed and refills. This process will help you learn how to write a prescription, which is very important in pediatrics since most medications are weight based. An example: For strep pharyngitis the recommended antibiotic is amoxicillin @ 50 mg/kg/day divided q12hr. Child’s weight = 17 kg = 850 mg/day. Amoxicillin’s strength = 400 mg/5 mL. Therefore the child is to take 5 mL po q12 hr x 10 days. Dispense 100 mL with 0 refills. Make sure to keep the SUBJECTIVE data (what the family/patient tells you) separate from your OBJECTIVE data (what you see, feel, hear, measure, etc..). These SOAP notes will be graded using the grading rubric provided with each weekly assignment. For more details of the elements of a great SOAP note, please see the document saved in Doc Sharing entitled Elements of a Great SOAP Note. Remember to due self assessments on each SOAP subject
elements_of_a_great_soap_note__1_.pdf
nsg_6435pediatric_soap_note_format.docx
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Elements of a great SOAP note
SUBJECTIVE data/information is the information that the patient/caregiver tells you and should not
include any of your observations. The SUBJECTIVE portions of the SOAP note include: Chief complaint,
child profile, HPI, medications, PMH, Family/social history and review of systems (ROS).
Who is giving the history?
What pt/caregiver(s) said in quotes.
Child Profile: All visits should include the
basic biological functioning assessment,
which includes nutrition, elimination, sleep,
school/daycare, relationships
(friends/family), sports/activities, safety
measures in place, and PAST developmental
history (if applicable) – not current.
HPI – is the History of the Present Illness –
for episodic visits you need to include all
pertinent questions to start developing your
differential diagnoses. Use OLDCARTS.
Medications taking and why (even OTCs) –
these are for current meds and not the ones
you prescribe at the current visit.
Past Medical History – for immunizations pls
list the vaccines received to date. For
adolescent pts (12 yo +), only list the ones
received after age 6 yo
Nuclear family medical history
Social history – who the pt LIVES with, living
environment, safety features of the house, is
he/she safe?, smoke/drugs/alcohol
exposure?
Review of Systems (still subjective)
These need to be age specific and
appropriate for the patient. You wouldn’t
ask a 6 month old if she’s experiencing chest
pain, for example.
For well visits, you need to review ALL of the
systems.
For episodic/sick visits, you need to have a
focused ROS. For example, you shouldn’t ask
a pt coming in with a CC of pharyngitis if
she’s having breast discharge. However, a
basic ROS should always include questions
regarding General, Cardio, Resp and GI,
along with the CC.
Medical/professional terminology should be
documented in the ROS. Instead of saying
“c/o sore throat” you should state
“+pharyngitis.”
OBJECTIVE data/information is any information that you can SEE, HEAR, FEEL or MEASURE. It includes
vitals and the exam details.
Growth curves: ALL SOAP notes must have
growth curves either uploaded to the
dropbox or copied/pasted onto the SOAP.
You can take a picture of the growth curve in
the chart on EMR (removing all pt identifiers)
and paste into the SOAP note. OR you can
get a blank growth curve online and plot the
data, then upload. For pts from birth to 2
years you need HEIGHT, WEIGHT, and HEAD
CIRCUMFERENCE. For pts >2 yo, then you
need HEIGHT, WEIGHT, and BMI.
Vital signs: use proper units (lb/kg, in/cm,
F/C, etc…)
The exam should use professional/medical
terminology.
For well visits: ALL systems have to be
examined, including breast and GU. For
these systems you need to document the
Tanner stages, along with the description.
For episodic visits: The exams should be
focused, but should always include
GENERAL, CARDIO, RESP, and GI.
For well visits: This section should include
any type of ASSESSMENT TOOL that you
used, the name of the tool, the results and
the rationale for the tool. For infants and
early childhood you should always include a
developmental assessment. For teens – any
type of depression/behavioral/risky behavior
screens.
For episodic visits: This section is N/A unless
the pt/caregiver expresses a concern OR if
something is detected in the Child
Profile/HPI/Social Hx/ROS. However, a
HEADSSSVG should be performed at every
adolescent visit.
Primary diagnosis & Differential Diagnoses
For well visits: You do not need a list of differentials if no abnormalities were detected.
For episodic visits: You need to make sure you indicate what the primary diagnosis is and then give
three RELATED differentials. Giving three actual diagnoses is not considered differentials. The
differential diagnoses are a group of diagnoses that share common elements and should start to form in
the HPI/ROS/Hx. The differentials are then narrowed with the exam and any test results. You will need
to give a couple of sentences of why you chose the diff and how you rule it out.
Plan of Care
The plan of care needs to be detailed. You cannot say “Patient education given regarding safety
practices.” This doesn’t let me know what YOU need to tell the patient. It should state, for a 2 month
old infant for example, put to sleep on back, no blankets/stuff animals in crib – these will prevent SIDS.
For medications you need to give the RECOMMENDED WEIGHT BASED DOSE. ALL meds in peds are
based on a child’s weight and are determined by clinical guidelines. You should indicate this
recommended weight based dose, as well as directions for taking the meds. You should also include
education about potential side effects.
All of the other components should be included, but are self-explanatory.
****
Up to this point the SOAP is based on what you and/or your clinical preceptor did during this patient’s
visit. If you preceptor gives you evidence-based (EB) guidelines, then you should indicate which one was
used, along with the diagnoses and plan of care. However, the most important part of the SOAP note is
the self-assessment, see grading rubric below.
The SOAP note grading rubric (more detail one can be found with the assignment description)
The Self-Assessment & Clinical Guidelines is one of the most important parts of the SOAP note. This
portion is where you critically analyze what you and/or your clinical preceptor did during the visit and
then you research CURRENT EB guidelines for the type of visit. You can always ask your clinical
preceptor what EB guidelines they’re using and why (make sure they’re the most recent guidelines
though). Once reading/learning about the EB guidelines, you examine to see if you/your clinical
preceptor followed these guidelines. If you did, then how. If not, then you need to describe how it
differed and why. Then you need to discuss what you would do differently for the next visit with a
similar patient. Simply stating that “My preceptor and I followed EB guidelines and I would do nothing
differently.” is not an acceptable self-assessment.
Pediatric SOAP Note
Name:
Date:
Sex:
Age/DOB/Place of Birth:
SUBJECTIVE
Historian:
Present Concerns/CC:
Reason given by the patient for seeking medical care “in quotes”
Child Profile: (Sexual History (If appropriate); ADLs (age appropriate); Safety Practices; Changes in daycare/school/after-school care;
Sports/physical activity; Developmental Hx)
HPI: (must include all components)
Medications: (List with reason for med )
PMH:
Allergies:
Medication Intolerances:
Chronic Illnesses/Major traumas:
Hospitalizations/Surgeries:
Immunizations:
Family History (Please identify all immediate family)
Social History Education level, occupational history, current living situation/partner/marital status, substance use/abuse, ETOH, tobacco, and
marijuana. Safety status
ROS
General
Cardiovascular
Skin
Respiratory
Pediatric SOAP Note
Eyes
Gastrointestinal
Ears
Genitourinary/Gynecological
Nose/Mouth/Throat
Musculoskeletal
Breast
Neurological
Heme/Lymph/Endo
Psychiatric
OBJECTIVE (plot height/weight/head circumference along with noting percentiles) Attach growth chart
Weight
Temp
BP
Height
Pulse
Resp
General Appearance and parent‐child interaction
Skin
HEENT
Cardiovascular
Respiratory
Gastrointestinal
Breast
Genitourinary
Pediatric SOAP Note
Musculoskeletal
Neurological
Psychiatric
In-house Lab Tests – document tests (results or pending)
Pediatric/Adolescent Assessment Tools (Ages & Stages, etc) with results and rationale
For adolescents (HEADSSSVG Assessment)
Diagnosis
➢
➢
➢
Include at least three differential diagnoses with ICD-10 codes. (Includes Primary dx and 2 differentials)
Document Evidence based Rationale for ROS and each differential with pertinent positives and
negatives
Primary diagnosis
✓ Is #1 on list of differentials
✓ Evidence for primary diagnosis should be supported in the Subjective and Objective exams.
PLAN including education
➢ Plan: Treatment plan should be for the Primary Diagnosis and based on EB literature.
➢ Include EB rationale for all aspects of your treatment plan:
✓ Vaccines administered this visit
✓ Vaccine administration forms given
✓ Medication-amounts and mg/kg for medications
✓ Laboratory tests ordered
✓ Diagnostic tests ordered
✓ Patient education including preventive care and anticipatory guidance
✓ Non-medication treatments
✓ Follow-up appointment with detailed plan of f/u
*ALL references must be Evidence Based (EB)
…
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