PEDIATRIC FILLABLE SOAP NOTE TEMPLATE
STUDENT NAME: Tiffany Swanson DATE OF ASSIGNMENT: 12/02/2019
Patient Initials: TA Date of Encounter: 10/05/2015
Sex: Male Age/DOB/Place of Birth: Unknown place of
brith
8/5/2013- 26 months
SUBJECTIVE
Historian:MOM
Present Concerns/CC:
"He isn’t himself. He is been whining alot and refusing to eat. He has been rubbing his tummy”
Child Profile:
26 month old Caucasian male with downs sundrome Mom atTEA “his milestones are different.
He can say a few words and he started walking later than his others two siblings for sure”. Mom
also reports he holds on tp furniture while walking and still wears diapers. Patient had a normal
birth and mom denies pregnancy issues. Patient is not in day and he is watched by the father
ofhis youngest sibling when mom is at work.
HPI: (must include all components - OLD CARTS)
The patient is 26 months old male with Down syndrome with a history of congestive heart
failure, and ASD s/p surgical . Came into the emergency room with his mother with complaints
of abdominal pain x two days, has vomited x1. Patient is lethargic, diaphoretic, breathing
rapidly and has decreased urine output. Abdomen grossly distened with a large bruise
approximately 10mcm in the lower portion.
O-2 DAYS ago
L-ABDOMEN
D-Constant
C-PAIN-UNABLE TO ASSESSCHARATERISTICA
A touching makes it worse- Nothing given to alleviate
R-Pain does not move
T-None
S-6/10 per mom
1|PEDIATRICSOAPNOTE
, PEDIATRIC FILLABLE SOAP NOTE TEMPLATE
Medications: (List with reason for meds)
None
PMH:
Boorn with Downs syndrome
CHF
Crdiac surgery
Allergies: NKA
Medication Intolerances: None
2|PEDIATRICSOAPNOTE
STUDENT NAME: Tiffany Swanson DATE OF ASSIGNMENT: 12/02/2019
Patient Initials: TA Date of Encounter: 10/05/2015
Sex: Male Age/DOB/Place of Birth: Unknown place of
brith
8/5/2013- 26 months
SUBJECTIVE
Historian:MOM
Present Concerns/CC:
"He isn’t himself. He is been whining alot and refusing to eat. He has been rubbing his tummy”
Child Profile:
26 month old Caucasian male with downs sundrome Mom atTEA “his milestones are different.
He can say a few words and he started walking later than his others two siblings for sure”. Mom
also reports he holds on tp furniture while walking and still wears diapers. Patient had a normal
birth and mom denies pregnancy issues. Patient is not in day and he is watched by the father
ofhis youngest sibling when mom is at work.
HPI: (must include all components - OLD CARTS)
The patient is 26 months old male with Down syndrome with a history of congestive heart
failure, and ASD s/p surgical . Came into the emergency room with his mother with complaints
of abdominal pain x two days, has vomited x1. Patient is lethargic, diaphoretic, breathing
rapidly and has decreased urine output. Abdomen grossly distened with a large bruise
approximately 10mcm in the lower portion.
O-2 DAYS ago
L-ABDOMEN
D-Constant
C-PAIN-UNABLE TO ASSESSCHARATERISTICA
A touching makes it worse- Nothing given to alleviate
R-Pain does not move
T-None
S-6/10 per mom
1|PEDIATRICSOAPNOTE
, PEDIATRIC FILLABLE SOAP NOTE TEMPLATE
Medications: (List with reason for meds)
None
PMH:
Boorn with Downs syndrome
CHF
Crdiac surgery
Allergies: NKA
Medication Intolerances: None
2|PEDIATRICSOAPNOTE
