SOAP Note for Well Child Exam (2 Year Old)

SOAP Note for Well Child Exam (2 Year Old)

Write a comprehensive SOAP note for a 2-year-old well child check.  Assume all findings are within normal limits.

 

Please include the following:

• A full subjective and objective assessment
• Appropriate Ht/Wt percentiles
• Developmental history and current developmental state (milestones)
• At least 3 differential diagnoses to consider (think about why we recommend well child checks)
• A final diagnosis indicating normal findings
• Your assessment and plan, including education and anticipatory guidance.

Intake Instructions

DOS:

ID:

Name:

DOB:

Age:

Gender:

 

SUBJECTIVE

Problem Statement/Chief complaint:

HPI (write in narrative style addressing POLDCARTS):

Allergies:

Medications:

Immunization Status:

Past Medical History:

Surgical History:

Birth History:

Growth and Developmental History:

Nutrition Status:

Family History:

Social History:

Review of Systems (pertinent)

·         General

·         Skin

·         HEENT

·         Neck/Lymph Nodes

·         Cardiovascular

·         Respiratory

·         GI

·         GU

·         Neurological

·         Psych

OBJECTIVE (pertinent exam)

Type:	Data/Measurement:
Height:
Weight:
BMI
BMI %tile
Heart Rate:
Blood Pressure:
Temperature:
RR:
Allergies:

 

General:

Skin:

HEENT:

Neck/Lymph Nodes:

Cardiovascular:

Pulmonary:

GI:

GU:

Neurologic:

Psych:

 

DIFFERENTIAL DIAGNOSES (at least 3)

Also include reasoning for ruling out Differential Diagnoses with evidence-based literature support:

 

Differential Diagnosis + Reasons for r/o:	Pertinent Positives/Negatives (Positives bold, negatives not bold)
1.)
2.)
3.)
4.)
5.)

 

ASSESSMENT: ICD 10

CPT Evaluation &Management (E&M) code:     

CPT procedure code(s):

 

TREATMENT PLAN

1. Anticipatory Guidance:
2. Patient Education:
3. Follow Up:

 

Thank you!