SU_NSG6435_Stevens_K.doc._week 9_Soap_note
(1)
Pediatric SOAP Note
NP Student Name: Kayla Stevens Child’s Initials: LD DOB: 03/04/201
Clinical Date: 06/25/2019 Age: 5 Place of Born: Douglas, GA
Sex: Type of Soap Note:
Week Soap Project: W9 M Well child visit X
F _X Sick visit
SUBJECTIVE
Historian: Parent
Present Concerns/CC: “She is here for her well-check, I think she has allergies”.
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 child dresses independently but does sometimes need help matching
outfits. The child brushes teeth independently at least twice per day. The child is learning to tie shoes but does require help.
The child settles for sleep independently. The child sleeps in her own bed. The child feeds self without difficulty.
Safety Practices: Home is childproofed with covers on electrical outlets, uses booster seat, able to swim, mother
states sunscreen is used, -tobacco/ETOH abuse, -falls, -lead, - TB exposure
Nutrition: Mother states that the child drinks 2% milk at least one cup daily. Mother states the child does drink juices
and koolaids. States that she attempts to ensure that the child drinks as much water as possible. States the child’s taste
in food changes from day to day, but she does try to ensure that she east plenty of fruits and vegetables.
Changes in daycare/school/after-school care: Stays at home with mother during the day while father works. Will be attending
kindergarten in the fall.
Sleep: The child sleeps in her bed at night and usually goes to sleep around 9 pm and wakes up at 8 am. Mother reports
child sleeps through the night. Does take one nap per day.
Sports/physical activity: NA
Developmental History:
- Gross motor: Hops, Skips, rides bicycle with training wheels, swims with no floaties.
- Fine motor: uses scissors, colors in the lines, can draw simple objects, manages buttons and zippers
- Cognitive: Follows simple directions, can draw shapes, knows colors, knows alphabet
- Social/Emotional: plays well with other children, able to follow the rules of games such as “Simon Says”.
- Communication: Has a large vocabulary. Clearly and easily
understood. Sexual History (if appropriate):NA
This study source was downloaded by 100000815611969 from CourseHero.com on 02-12-2023 22:59:39 GMT -06:00
Revised 5/9/18; 8/9/18; 10/29/18
https://www.coursehero.com/file/43415065/SU-NSG6435-Stevens-Kdoc-week-9-Soap-note-1docx/
, SU_NSG6435_Stevens_K.doc._week 9_Soap_note
(1)
HPI:
The patient is a 5 year old Hispanic female who presents with her mother for her 5 year old health check. Mother states she feels
as though she is “doing well”. States that she feels as though she is progressing quicker developmentally than her son did when he
was her age. States that her current favorite food is chicken nuggets, but she does ensure that the child has at least one well-
balanced meal per day. States that the child does sleep in her bed alone, but still requires her favorite stuffed animal she has had
since she was two years old to be in the bed with her. States she sleeps with a night light on. Mother states she is concerned that her
child has “allergies”. Child states “my nose is stuffy and I sneeze after being outside a lot”. Mother states they do live near pecan
trees which she fears is the cause of the allergies. 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 pain or fever.
This study source was downloaded by 100000815611969 from CourseHero.com on 02-12-2023 22:59:39 GMT -06:00
Revised 5/9/18; 8/9/18; 10/29/18
https://www.coursehero.com/file/43415065/SU-NSG6435-Stevens-Kdoc-week-9-Soap-note-1docx/
(1)
Pediatric SOAP Note
NP Student Name: Kayla Stevens Child’s Initials: LD DOB: 03/04/201
Clinical Date: 06/25/2019 Age: 5 Place of Born: Douglas, GA
Sex: Type of Soap Note:
Week Soap Project: W9 M Well child visit X
F _X Sick visit
SUBJECTIVE
Historian: Parent
Present Concerns/CC: “She is here for her well-check, I think she has allergies”.
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 child dresses independently but does sometimes need help matching
outfits. The child brushes teeth independently at least twice per day. The child is learning to tie shoes but does require help.
The child settles for sleep independently. The child sleeps in her own bed. The child feeds self without difficulty.
Safety Practices: Home is childproofed with covers on electrical outlets, uses booster seat, able to swim, mother
states sunscreen is used, -tobacco/ETOH abuse, -falls, -lead, - TB exposure
Nutrition: Mother states that the child drinks 2% milk at least one cup daily. Mother states the child does drink juices
and koolaids. States that she attempts to ensure that the child drinks as much water as possible. States the child’s taste
in food changes from day to day, but she does try to ensure that she east plenty of fruits and vegetables.
Changes in daycare/school/after-school care: Stays at home with mother during the day while father works. Will be attending
kindergarten in the fall.
Sleep: The child sleeps in her bed at night and usually goes to sleep around 9 pm and wakes up at 8 am. Mother reports
child sleeps through the night. Does take one nap per day.
Sports/physical activity: NA
Developmental History:
- Gross motor: Hops, Skips, rides bicycle with training wheels, swims with no floaties.
- Fine motor: uses scissors, colors in the lines, can draw simple objects, manages buttons and zippers
- Cognitive: Follows simple directions, can draw shapes, knows colors, knows alphabet
- Social/Emotional: plays well with other children, able to follow the rules of games such as “Simon Says”.
- Communication: Has a large vocabulary. Clearly and easily
understood. Sexual History (if appropriate):NA
This study source was downloaded by 100000815611969 from CourseHero.com on 02-12-2023 22:59:39 GMT -06:00
Revised 5/9/18; 8/9/18; 10/29/18
https://www.coursehero.com/file/43415065/SU-NSG6435-Stevens-Kdoc-week-9-Soap-note-1docx/
, SU_NSG6435_Stevens_K.doc._week 9_Soap_note
(1)
HPI:
The patient is a 5 year old Hispanic female who presents with her mother for her 5 year old health check. Mother states she feels
as though she is “doing well”. States that she feels as though she is progressing quicker developmentally than her son did when he
was her age. States that her current favorite food is chicken nuggets, but she does ensure that the child has at least one well-
balanced meal per day. States that the child does sleep in her bed alone, but still requires her favorite stuffed animal she has had
since she was two years old to be in the bed with her. States she sleeps with a night light on. Mother states she is concerned that her
child has “allergies”. Child states “my nose is stuffy and I sneeze after being outside a lot”. Mother states they do live near pecan
trees which she fears is the cause of the allergies. 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 pain or fever.
This study source was downloaded by 100000815611969 from CourseHero.com on 02-12-2023 22:59:39 GMT -06:00
Revised 5/9/18; 8/9/18; 10/29/18
https://www.coursehero.com/file/43415065/SU-NSG6435-Stevens-Kdoc-week-9-Soap-note-1docx/
