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Please see attach file for example of a soap note
Complete a SOAP NOTE on a pediatric patient with Respiratory or Cardiovascular Patient
Please include a heart exam and lung exam on all clients regardless of the reason for seeking care. So, if someone presented with cough and cold symptoms, you would examine the General appearance, HEENT, Neck, Heart and Lungs for a focused/episodic exam. The pertinent positive and negative findings should be relevant to the chief complaint and health history data. This template is a great example of information documented in a real chart in clinical practice. The only section that will not be included in a real chart is differential diagnosis. The term “Rule Out…” cannot be used as a diagnosis.
Subjective Data
Chief Complain (CC):
History of Present Illness (HPI):
Last Menstrual Period (LMP- if applicable)
Allergies:
Past Medical History:
Family History:
Surgery History:
Social History (alcohol, drug, or tobacco use):
Current medications:
Review of Systems
(Remember to inquire about body systems relevant to the chief complaint and HPI)
Objective Data
Please remember to include an assessment of all relevant systems based on the CC and HPI. The following systems are required in all SOAP notes. If it is a child, include the Tanner stage. You will proceed to assess pertinent systems.
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