NSG 6435 Family Health III-Pediatrics WEEK 3 SOAP NOTE TEMPLATE.

NSG 6435 Family Health III-Pediatrics WEEK 3 SOAP NOTE TEMPLATE. PEDIATRIC FILLABLE SOAP NOTE TEMPLATE STUDENT NAME: Amy Brown DATE OF ASSIGNMENT: 03/12/2019 Patient Initials: M.L. Date of Encounter: 03/07/2019 Sex: Male Age/DOB/Place of Birth: 7 year old male 11/21/2011 Cape Coral, FL SUBJECTIVE Historian: Mother Present Concerns/CC: 7 year old Caucasian male accompanied by his mother with complaints of seeing lights and spacing out. The mother states that her son stares into space and she tries to snap him out of it and nothing works. Child Profile: Child attends public school and is doing well according to his mother. HPI:O: Child has been having episodes where he stares into space x6 months. L: There is no specific location as the child does not know it is happening D: Per the mother the episodes usually last 10-30 seconds C: No specific character, the child is non responsive A: Per the mother there does not seem to be any aggravating factors R: No relieving factors, the child eventually snaps out of it T: It does not occur at any specific time of the day S: The episodes do not vary in severity This study source was downloaded by from CourseH on :04:33 GMT -06:00 Medications: None PMH: The child has been diagnosed with mild ADHD and there has been question whether or not the patient is autistic. He is currently receiving behavioral therapy for the ADHD and his mother states that it seems to be working well. Allergies: None Medication Intolerances: None noted Chronic Illnesses/Major traumas: none Hospitalizations/Surgeries: none Immunizations: up to date.