NR 509 Week 6 Pediatric SOAP Note, Summer 2020 complete
solution.
NR 509 Week 6 Pediatric SOAP Note S: Subjective – Information the patient or patient
representative told you O: Objective – Information gathered during the physical
examination by inspection, palpation, auscultation, and palpation. If unable to assess a
body system, write “Unable to assess”. Document pertinent positive and negative
assessment findings. A: Assessment – Medical Diagnoses. Provide 3 differential diagnoses
which may provide an etiology for the CC. The first diagnosis (presumptive diagnosis) is
the diagnosis with the highest priority. Provide the ICD-10 code and pertinent findings to
support each diagnosis. P: Plan – Address all 5 parts of the comprehensive treatment
plan. If you do not wish to order an intervention for any part of the treatment plan,
write “None at this time” but do not leave any heading blank. No intervention is self-
evident. Provide a rationale and evidence-based in-text citation for each intervention.
, SOAP Note Template
S: Subjective
Information the patient or patient representative told you
Initials: DR Age: 8 Gender: Male
Height Weight BP HR RR Temp SPO2 Pain Allergies (and reaction)
Rating
127cm 40.9kg 120/ 100 28 37.2C 96% Medication: No known allergies
76 Food: No known allergies
Environment: No known allergies
History of Present Illness (HPI)
Chief Complaint (CC) Ear pain, cough, sore throat CC is a BRIEF statement identifying
Onset 5 days ago (cough, sore throat), 1 day ago (ear pain) why the patient is here - in the
Location Ear, throat patient’s own words - for instance
"headache", NOT "bad headache for 3
Duration Cough is every couple minutes
days”. Sometimes a patient has more
Characteristics Ear: 3/10, no discharge than one complaint. For example: If
Throat: 2/10, a little pain when swallowing the patient presents with cough and
Cough: Wet, with clear sputum sore throat, identify which is the CC
Aggravating Factors Worse at night and which may be an associated
symptom
Relieving Factors Only temporarily relieved by medications
Treatment Unknown purple cough syrup (one spoonful)
Current Medications: Include dosage, frequency, length of time used and reason for use; also include OTC or homeopathic products.
Medication Length of Time
Dosage Frequency Reason for Use
(Rx, OTC, or Homeopathic) Used
Multivitamin 1 gummy Daily Unknown Daily maintanence
Purple cough medication 1 spoonful Once Today Cough suppressant
Past Medical History (PMHx) – Includes but not limited to immunization status (note date of last tetanus for all adults), past major illnesses,
hospitalizations, and surgeries. Depending on the CC, more info may be needed.
Reported history of ear infections at 2 years old. Pneumonia last year. Frequent complaints of rhinorrhea and cough. Immunizations up to date.
Denies asthma. Denies past inhaler usage, denies previous hospitalizations. No surgical history. No influenza vaccine in past 12 months.
solution.
NR 509 Week 6 Pediatric SOAP Note S: Subjective – Information the patient or patient
representative told you O: Objective – Information gathered during the physical
examination by inspection, palpation, auscultation, and palpation. If unable to assess a
body system, write “Unable to assess”. Document pertinent positive and negative
assessment findings. A: Assessment – Medical Diagnoses. Provide 3 differential diagnoses
which may provide an etiology for the CC. The first diagnosis (presumptive diagnosis) is
the diagnosis with the highest priority. Provide the ICD-10 code and pertinent findings to
support each diagnosis. P: Plan – Address all 5 parts of the comprehensive treatment
plan. If you do not wish to order an intervention for any part of the treatment plan,
write “None at this time” but do not leave any heading blank. No intervention is self-
evident. Provide a rationale and evidence-based in-text citation for each intervention.
, SOAP Note Template
S: Subjective
Information the patient or patient representative told you
Initials: DR Age: 8 Gender: Male
Height Weight BP HR RR Temp SPO2 Pain Allergies (and reaction)
Rating
127cm 40.9kg 120/ 100 28 37.2C 96% Medication: No known allergies
76 Food: No known allergies
Environment: No known allergies
History of Present Illness (HPI)
Chief Complaint (CC) Ear pain, cough, sore throat CC is a BRIEF statement identifying
Onset 5 days ago (cough, sore throat), 1 day ago (ear pain) why the patient is here - in the
Location Ear, throat patient’s own words - for instance
"headache", NOT "bad headache for 3
Duration Cough is every couple minutes
days”. Sometimes a patient has more
Characteristics Ear: 3/10, no discharge than one complaint. For example: If
Throat: 2/10, a little pain when swallowing the patient presents with cough and
Cough: Wet, with clear sputum sore throat, identify which is the CC
Aggravating Factors Worse at night and which may be an associated
symptom
Relieving Factors Only temporarily relieved by medications
Treatment Unknown purple cough syrup (one spoonful)
Current Medications: Include dosage, frequency, length of time used and reason for use; also include OTC or homeopathic products.
Medication Length of Time
Dosage Frequency Reason for Use
(Rx, OTC, or Homeopathic) Used
Multivitamin 1 gummy Daily Unknown Daily maintanence
Purple cough medication 1 spoonful Once Today Cough suppressant
Past Medical History (PMHx) – Includes but not limited to immunization status (note date of last tetanus for all adults), past major illnesses,
hospitalizations, and surgeries. Depending on the CC, more info may be needed.
Reported history of ear infections at 2 years old. Pneumonia last year. Frequent complaints of rhinorrhea and cough. Immunizations up to date.
Denies asthma. Denies past inhaler usage, denies previous hospitalizations. No surgical history. No influenza vaccine in past 12 months.
