Sample soap note for wellness visit

Running Head: TWO YEAR SOAP NOTE Two-year SOAP NOTE 2 YEAR SOAP NOTE Name: K. H Date: 5th SEP 2017 1 TWO YEAR SOAP NOTE Sex: MALE 2 Age: 2 YEARS DOB: 21 JULY 2015 Place of Birth: White Plains- New York SUBJECTIVE Historian: Mother Purpose Well child check up Present Concerns/CC: “the toddler produces clear mucous.” “he is chewing his fingers” “he has a runny nose that has been around for 8 days.” Child Profile The child had had a runny nose for around 3 days clear drainage no fever. He has no weight loss. He has no any sexual history. He has had otitis media of right ear 6 months ago. There are various safety practices on the child. Some of the practices include keeping all the The reasonproducts is given by the from patient seeking medical careof “in quotes.” household away thefor child’s reach. Locking doors in areas where the child might experience serious warms. Removal of furniture with sharp edges within the room of the child or in areas where the child might get in contact with them. Other safety practices include keeping all medicine out of sight and reach of the child. Keeping all medicine caps tight. The development of the child has been normal. TWO YEAR SOAP NOTE HPI: The child has never been critically ill. He had never hospitalized before though he was born prematurely. The victim experiences are swelling within the eyes. There are no major surgeries done at the infant as well as the prevalence of any major traumas. Some of the pertinent positives of normal development include verbal direction following, can recite half his ABC’s and spell his name abit, some clear drainage noted mucus. Upon oral inspection, the child is noted to be cutting a right molar. Pertinent negatives include running nose. Some of the aggregating positives include no coughing, as well as, no colored drainage, no temperature. The alleviating factors include reduced runny nose in when the baby is warmly dressed or does not come into contact with coldness Medications: Acetaminophen- prn every 4 to 6 hours dose acetaminophen based on a child's weight, using 10 mg/kg/dose. Educate parents on proper dosage and lbs to kg conversion age 2 years PMH: Allergies: The child is allergic to cow milk, pollen, and fur Medication Intolerances: K. H has aspirin and antibiotic medical intolerance Chronic Illnesses/Major traumas: The toddler has not had any major traumas or any other cases of chronic illnesses in his health history other than ear infection note 6 months ago Hospitalizations/Surgeries: Immunizations: The child has not had any kind of hospitalizations or major traumas 3 TWO YEAR SOAP NOTE 4 Family History The father of the patient is trying to manage her sugar levels as he has been diagnosed with diabetes. The mother has been having cases of high blood pressure. One of the siblings of the client has been diagnosed with asthma. The other sibling is health with no cases of cancer reported in the family. Social History The baby is active in his day care. No education or occupational history on the patient as he is Only a 2-year infant. The child is living with his two parents and siblings. The parents have a sound financial status, hence able to give the baby the comfort that he deserves. The home is safe with no cases of insecurity in the neighborhood. There no history of alcohol, tobacco, ETOH or marijuana abuse on the child ROS General Cardiovascular The baby appears healthy. Neatly dressed and There are no reported cases of orthopnea, PND or good weight. edema. The palpitations are normal with o cases of chest pains. The heart rate is normal Skin