Pediatric SOAP Note
NP Student Name: Kayla Stevens Child’s Initials: LS DOB: 06/12/2016
Clinical Date: 07/02/2019 Age: 3 Place of Born: Douglas, GA
Sex: Type of Soap Note:
Week Soap Project: W10 M X_ Well child visit
F Sick visit X
SUBJECTIVE
Historian: Parent
Present Concerns/CC: "I think he has tonsillitis again"
Child Profile: (complete the areas listed as appropriate; may omit an area if not appropriate to the client)
Activities of Daily Living (age appropriate): The toddler is toilet trained but does continue to wear pull ups as he does still have
“accidents”. The toddler feed himself with a spoon and fork. The toddler can drink from a cup. The toddler brushes teeth with
help. The toddler does require help dressing.
Safety Practices: Home is childproofed with covers on electrical outlets, chain locks, and cabinet locks, uses car seat, mother
states sunscreen is used, -tobacco/ETOH abuse, -falls, -lead, - TB exposure
Nutrition: Mother states that the child drinks 2% milk approximately 2 cups per day. States that the child drinks juice and
soda occasionally. States the child is a picky eater and is currently only wanting to eat “mac and cheese” but she does try to
ensure that he has vegetables and well balanced meals.
Changes in daycare/school/after-school care: No changes. Attends day care while mother and father work during the day.
Sleep: The toddler sleeps with mother and father in their bed. The toddler usually goes to sleep around 9pm and wakes up at 8
am. Mother reports toddler sleeps through the night. Does take one nap per day.
Sports/physical activity: NA
Developmental History:
- Gross motor: Walks up/down steps, able to kick a ball with direction, jumps with both feet, can catch a ball, rides a
tricycle, dresses with assistance
- Fine motor: Scribbles on paper, colors pages, can build a tower of 9-10 cubes, puts on shoes, uses scissors, copies circle
- Cognitive: Follows simple commands, names items in pictures, knows colors, knows shapes, can count to 10.
- Social/Emotional: plays well alongside other children, does occasionally have a difficult time sharing toys, enjoys
pretend play such as pretending to be a policeman or cowboy
- Communication: Speaks in 3-4 word
sentences. Sexual History (if appropriate):NA
HPI:
The patient is a 3-year-old white male who presents with his mother secondary to fever and vomiting X 2 days. States she thinks
tonsils are swollen and this gagged him and caused vomiting. Mother states they have been rotating Tylenol and ibuprofen at
home for fever. States she fears it is tonsillitis again, states this is the 3rd time the child has had it this year. Denies any further
complaints at present.
Medications:
No prescribed medications. Mother states she does give her OTC Children’s Tylenol and Motrin as needed for his fever.
PMH:
Allergies: NKDA
his study source was downloaded by 100000852681095 from CourseHero.com on 12-02-2022 19:55:38 GMT -06:00
T
Revised 5/9/18; 8/9/18; 10/29/18
https://www.coursehero.com/file/43415061/Week-10-soap-notedocx/
, Pediatric SOAP Note
Chronic Illnesses/Major traumas: None reported
Hospitalizations/Surgeries: None reported
Immunizations: Up-to-date
Family Medical History (Identify all immediate family members, their age, & health status)
Mother: 39-year-old white female with diabetes; II.
Father: 42-year-old white male with high hypertension
Older sibling (10 year old male)- no known health problems
Social History (complete the areas listed as appropriate; may omit an area if not appropriate to the client)
Current living situation/p-artner/marital status: Lives at home with mother, father, and older sibling.
Educational level (as appropriate): NA
Occupational history (as appropriate): NA
Substance use/abuse (ETOH, tobacco, and marijuana): NA
Firearms in home: Father has guns which mother states are stored in a locked safe
Safety status: Home is childproofed with covers on electrical outlets, chain locks, and cabinet locks, uses car seatmother
states sunscreen is used, -tobacco/ETOH abuse, -falls, -lead, - TB exposure
REVIEW OF SYSTEMS
(Do not omit any body system & remember this is a child not an
adult)
General: Cardiovascular:
Mother reports fever and fatigue. Mother denies Mother denies chest pain, palpitations, PND, orthopnea,
decreased appetite. Denies difficulty sleeping, chills, edema
malaise, night sweats, unexplained weight loss or weight
gain.
Skin: Respiratory:
Mother denies delayed healing, rashes, bruising, bleeding Mother denies cough, wheezing, hemoptysis, dyspnea,
or skin discolorations, any changes in lesions or moles pneumonia hx, TB
Head: Breast:
Mother denies headaches, concussions, unusual head Mother denies lumps, bumps or changes
shape
Eyes: Gastrointestinal:
Mother denies corrective lenses, blurring, visual changes Mother reports vomiting x 2. Mother denies abdominal
of any kind pain, Diarrhea. Denies constipation, hepatitis, hemorrhoids,
eating disorders, ulcers, black tarry stools
Ears: Musculoskeletal:
Mother denies ear pain, hearing loss, ringing in ears, Mother denies back pain, joint swelling, stiffness or
discharge pain, fracture hx, osteoporosis
This study source was downloaded by 100000852681095 from CourseHero.com on 12-02-2022 19:55:38 GMT -
Revised 5/9/18; 8/9/18; 10/29/18
https://www.coursehero.com/file/43415061/Week-10-soap-
NP Student Name: Kayla Stevens Child’s Initials: LS DOB: 06/12/2016
Clinical Date: 07/02/2019 Age: 3 Place of Born: Douglas, GA
Sex: Type of Soap Note:
Week Soap Project: W10 M X_ Well child visit
F Sick visit X
SUBJECTIVE
Historian: Parent
Present Concerns/CC: "I think he has tonsillitis again"
Child Profile: (complete the areas listed as appropriate; may omit an area if not appropriate to the client)
Activities of Daily Living (age appropriate): The toddler is toilet trained but does continue to wear pull ups as he does still have
“accidents”. The toddler feed himself with a spoon and fork. The toddler can drink from a cup. The toddler brushes teeth with
help. The toddler does require help dressing.
Safety Practices: Home is childproofed with covers on electrical outlets, chain locks, and cabinet locks, uses car seat, mother
states sunscreen is used, -tobacco/ETOH abuse, -falls, -lead, - TB exposure
Nutrition: Mother states that the child drinks 2% milk approximately 2 cups per day. States that the child drinks juice and
soda occasionally. States the child is a picky eater and is currently only wanting to eat “mac and cheese” but she does try to
ensure that he has vegetables and well balanced meals.
Changes in daycare/school/after-school care: No changes. Attends day care while mother and father work during the day.
Sleep: The toddler sleeps with mother and father in their bed. The toddler usually goes to sleep around 9pm and wakes up at 8
am. Mother reports toddler sleeps through the night. Does take one nap per day.
Sports/physical activity: NA
Developmental History:
- Gross motor: Walks up/down steps, able to kick a ball with direction, jumps with both feet, can catch a ball, rides a
tricycle, dresses with assistance
- Fine motor: Scribbles on paper, colors pages, can build a tower of 9-10 cubes, puts on shoes, uses scissors, copies circle
- Cognitive: Follows simple commands, names items in pictures, knows colors, knows shapes, can count to 10.
- Social/Emotional: plays well alongside other children, does occasionally have a difficult time sharing toys, enjoys
pretend play such as pretending to be a policeman or cowboy
- Communication: Speaks in 3-4 word
sentences. Sexual History (if appropriate):NA
HPI:
The patient is a 3-year-old white male who presents with his mother secondary to fever and vomiting X 2 days. States she thinks
tonsils are swollen and this gagged him and caused vomiting. Mother states they have been rotating Tylenol and ibuprofen at
home for fever. States she fears it is tonsillitis again, states this is the 3rd time the child has had it this year. Denies any further
complaints at present.
Medications:
No prescribed medications. Mother states she does give her OTC Children’s Tylenol and Motrin as needed for his fever.
PMH:
Allergies: NKDA
his study source was downloaded by 100000852681095 from CourseHero.com on 12-02-2022 19:55:38 GMT -06:00
T
Revised 5/9/18; 8/9/18; 10/29/18
https://www.coursehero.com/file/43415061/Week-10-soap-notedocx/
, Pediatric SOAP Note
Chronic Illnesses/Major traumas: None reported
Hospitalizations/Surgeries: None reported
Immunizations: Up-to-date
Family Medical History (Identify all immediate family members, their age, & health status)
Mother: 39-year-old white female with diabetes; II.
Father: 42-year-old white male with high hypertension
Older sibling (10 year old male)- no known health problems
Social History (complete the areas listed as appropriate; may omit an area if not appropriate to the client)
Current living situation/p-artner/marital status: Lives at home with mother, father, and older sibling.
Educational level (as appropriate): NA
Occupational history (as appropriate): NA
Substance use/abuse (ETOH, tobacco, and marijuana): NA
Firearms in home: Father has guns which mother states are stored in a locked safe
Safety status: Home is childproofed with covers on electrical outlets, chain locks, and cabinet locks, uses car seatmother
states sunscreen is used, -tobacco/ETOH abuse, -falls, -lead, - TB exposure
REVIEW OF SYSTEMS
(Do not omit any body system & remember this is a child not an
adult)
General: Cardiovascular:
Mother reports fever and fatigue. Mother denies Mother denies chest pain, palpitations, PND, orthopnea,
decreased appetite. Denies difficulty sleeping, chills, edema
malaise, night sweats, unexplained weight loss or weight
gain.
Skin: Respiratory:
Mother denies delayed healing, rashes, bruising, bleeding Mother denies cough, wheezing, hemoptysis, dyspnea,
or skin discolorations, any changes in lesions or moles pneumonia hx, TB
Head: Breast:
Mother denies headaches, concussions, unusual head Mother denies lumps, bumps or changes
shape
Eyes: Gastrointestinal:
Mother denies corrective lenses, blurring, visual changes Mother reports vomiting x 2. Mother denies abdominal
of any kind pain, Diarrhea. Denies constipation, hepatitis, hemorrhoids,
eating disorders, ulcers, black tarry stools
Ears: Musculoskeletal:
Mother denies ear pain, hearing loss, ringing in ears, Mother denies back pain, joint swelling, stiffness or
discharge pain, fracture hx, osteoporosis
This study source was downloaded by 100000852681095 from CourseHero.com on 12-02-2022 19:55:38 GMT -
Revised 5/9/18; 8/9/18; 10/29/18
https://www.coursehero.com/file/43415061/Week-10-soap-
