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Write an entire SOAP for the well child visit th

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Write an entire SOAP for the well child visit th

 

  • Write an entire SOAP for the well child visit that took place during immersion. For the child, please use the history you obtained during your encounter. For the chief complaint of all notes, you will write “well visit.” Please use your AAP Bright Future’s guide as the main resource for this assignment. Note that pediatrics will require more information than most SOAP notes, including percentiles for Ht/Wt/BMI, and developmental history, among other differences.
  • Please plot the height, weight, and BMI for your child on a growth chart (samples can be found on CDC) and include the growth chart with your submission.
  • Make sure you include a developmental assessment, and for pre-teens and teens, a HEEADSSS assessment.
  • Preferably, use the format described at immersion by using one of the templates in week one of the course. Make sure to include an assessment (diagnosis) and plan. Do not perform a risk assessment, but use actual diagnosis terminology. Be sure to use APA format and include references. Review the rubric before you begin working on the assignment.

Criteria

Exceeds Expectations

Meets Expectations

Below Expectations

Far Below Standard

Identifying Data

5 points

Correctly lists all components of the Identifying data including initials, age, DOB, gender, race, ethnicity and whether they came to clinic alone or accompanied and if they are a reliable historian.

4 points

Missing one of the elements, or not written in a complete/logical sentence.

2 points

Missing 2 or more items.

0 points

Not included or written in the wrong area (only in HPI instead of separately).

Chief Complaint

5 points

Listed the chief complaint in patient’s own words with quotation marks “complaint”. CC is brief and not over a sentence long.

4 points

Missing one element (not in quotations, not in patients own words, etc).

2 points

Incomplete not in the patient’s own words.

0 points

Not Included

History of present illness

15 points

HPI written succinctly in paragraph format. If the patient has no complaints (such as a wellness visit), the student summarizes the past health history including mo/year of last physical and any pertinent health maintenance or recent lab work.

For problem visits, the HPI narrates a story of the patient’s problem. If there is a complaint, all elements of HPI are addressed (OLDCARTs or OPQRST) as appropriate for complaint.

13 points

Most elements addressed, missing one or two items, but not missing an item that would severely change the treatment of patient.

10 points

For any complaint, missing 3 or more of the 7 HPI elements. Or for an annual exam, missing health maintenance history or summary of patient’s overall health. Missing an item that would alter the treatment.

7 points

<5 variables identified, or not included. May give a zero if not included. Did not provide a synopsis of the patient’s problem or health status.

Past Medical History

15 points

All elements of PMH are described, including medical problem list, surgical history with mo./year of procedure or hospitalization, allergies to environment, food, and drugs, list of meds with doses, and any chemical history (alcohol, drugs, tobacco, caffeine), immunization status. LMP must be included for women of child bearing age. For problem visit, the medical history is pertinent to the problem but meets minimum safety requirements, and always included smoking and allergy information.

For wellness exam student expands on diet/nutrition history as well as well as immunizations and health maintenance activities (exercise, sleep, stress).

12 points

Mostly complete; missing 1-2 items. May provide too much detail for problem focused visit, or too little detail for wellness exam.

9 points

Incomplete, missing 3-4 items or too little detail.

7 points

Missing more than half the information. May give a zero if not included.

Family History and Social History

10 points

For wellness visit, student must include list of relatives including siblings, children, parents, and grandparents and list ages and health problems.

For problem visit, provides family history that is pertinent to the problem, such as asking patient about family hx of GI diseases if the pt has a GI compliant.

Social history: Student includes occupation, education, housing situation, marital or relationship status, sexual history and practices, spiritual history, and safety practices (guns in home, seat belts, etc., and elaborates even more for children).

For problem focused visit, the student includes the social aspects that are pertinent to the problem.

8 points

Mostly complete; missing 1-2 items, or giving far too much detail than would be required for problem focused visit (i.e writing about every sexual partner or onset of menses on a visit for simple earache) or documenting too little information for a wellness exam.

6 points

Incomplete, missing 3 or more items, or far too much documentation than is required.

4 points

Missing more than half the information. May give a zero if not included.

Review of Systems

15 points

Student includes a complete ROS for an annual/wellness exam and an expanded or problem pertinent ROS for a problem-focused visit.

The student asks several questions in each category that pertains to the visit.

For a wellness exam, the student should review all systems.

The student uses the official 14 systems as outlined by page 7 of DHHS/CMS. DHHS/CMS official documentation

12 points

Mostly complete; missing 1-2 items. Student may have extra/unnecessary systems for a problem visit or missing 1-2 systems on a wellness exam.

10 points

Not comprehensive or not problem focused. Asked only 1 question from each system, or missing more than 2-3 systems, or, for problem focused, contained many extraneous, unnecessary items. Or used an ROS list that is not official.

8 points

Incomplete or missing pertinent positives, incomplete or missing pertinent negatives, more than half systems missing. May give a zero if ROS not performed.

Objective/Physical Exam Write Up

15 points

For all visits, includes vital signs. All peds visits include H/W.

For wellness exams and as needed for other visits, includes height/weight/BMI, head circumference (< 2 y.o.).

Includes proper documentation of comprehensive physical exam findings with proper medical terminology, as appropriate for the patient’s complaint.

A full physical is written up for an annual/wellness exam.

Exam is age appropriate (includes tanner stages and primitive reflexes as applies to children and infants)

12 points

May have missed 1-2 aspects of the physical exam write up, or included extra systems that are not necessary for the patient complaint. Some terminology is inappropriate or not professional (i.e. using laymen’s terms or non-medical terms).

9 points

Missed vital signs or several aspects of the physical exam write up. Included items that do not align with the complaint.

6 points

Missing over half of the physical exam.

Assessment and Plan

15 points

Student provides a DDX list with at least 3 differentials considered. Student indicates their chosen diagnosis and brief written synopsis of decision making for the diagnosis.

Treatment plan includes diagnostic plan, therapeutic plan, patient education (including SEs of meds if ordered) and specific follow up. For well child exams, includes anticipatory guidance/next immunizations. Student specifies labs and radiology and referrals as needed.

Student documents any ordered medications as appropriate at provider level; with correct medication form, doses, routes, timing, # ordered, and refills if indicated.

12 points

Assessment and plan is mostly complete, maybe missing one element. Did not include DDx list. Missing a detail of the prescription. Missing details of labs or rads or referrals.

10 points

Student is missing or several elements of plan or did not clearly indicate the diagnosis. Only mentions the prescription name.

5 points

Missing over half the A/P elements, or if not included at all may score the student a zero

Format, spelling/grammar, and references

10 points

APA format, spelling, and grammar is appropriate. Sentence fluency is present and content is organized and well-written.

SOAP note format is organized and easy to follow with clear headings for ID, CC, HPI, History, ROS, VS/PE, Assessment, and Plan and all subsections.

There are at least two in-text citations (with matching references) to support the clinical decision making (i.e. support the DX or the treatment plan chosen).

Student uses references that are evidence-based, peer-reviewed, and published within the last 5 years and that align with the scope of practice (i.e. provider focused references vs only nursing focused).

8 points

APA format is mostly correct with minimal errors.

The format has 1-2 errors but they are minor.

The student only uses one reference, or does not cite or write the references appropriately.

6 points

Several formatting or APA issues. Student does not use citations or references, or they chose references that are inappropriate.

4 points

Very poor or no APA format, poor SOAP format, or missing a portion of the SOAP note, or does not use any references.

,

· Write an entire SOAP for the well child visit that took place during immersion. For the child, please use the history you obtained during your encounter. For the chief complaint of all notes, you will write “well visit.” Please use your AAP Bright Future’s guide as the main resource for this assignment. Note that pediatrics will require more information than most SOAP notes, including percentiles for Ht/Wt/BMI, and developmental history, among other differences.

· Please plot the height, weight, and BMI for your child on a growth chart (samples can be found on CDC) and include the growth chart with your submission.

· Make sure you include a developmental assessment, and for pre-teens and teens, a HEEADSSS assessment.

· Preferably, use the format described at immersion by using one of the templates in week one of the course. Make sure to include an assessment (diagnosis) and plan. Use actual diagnosis terminology. Be sure to use APA format and include references. Review the rubric before you begin working on the assignment.

RB is a 7yr old pt. who presents to the clinic for a routine well child checkup visit with his parents. He is not an established patient. Today he weighs 51.8 lbs and is 122cm tall, as measured in the clinic.

BP: 94/60 P:80 RR:20 T: 98.4F

DOB: 9/18/14

Last check up: LAST YEAR

No hospitalization/surgery

No past hx

No medication

No allergies other than peanuts, asking for refill of epipen

Has pets: 1 dog

Eats fruits and vegetables “eats very good” as per mother. Likes candies

No concerns with developments

1st grade, very sociable, makes friends, plays baseball. No bullying

Flu Shot January

Siblings: 13, 5, 6, 1 years old: no health problems noted

Last Dental Appointment: March

Last Eye Appointment: January

RB plays with siblings, helps with chores, very independent, little bossy, sleeps well, balance with outside games

Safety

Dad lives with them. Stay at home mom

No guns, no relocation, booster seat, buckle up for safety

Bicycle

Swimming pool, lifeguard watching

Lives in a 50-year-old house—screen for lead and asbestos

Grandparents: cancer, hypertension, diabetes

No smoking no etoh and recreational drugs

>Calculate the height and weight percentiles, BMI and BMi percentile using an app or website.

>Is there an immunization record? If so, check it against the immunization schedule (CDC) are any due?

Diagnosis:

1. encounter for well child exam

2. encounter for immunization

3. Allergy to peanuts

>>Offer education about immunization

>>prescribe epipen for allergy to peanuts

>>Subjective: Add CDC immunization schedule applicable to patient.

>>Objective: Plot Growth Chart

All answers to these questions were all normal

Pediatric Interview and Well Child Exam – suggestions

Preschool and School aged (3-12)

INTRODUCTION

Introduce self to parent.

Maintain good eye contact with parent.

Inquire about the reason for the visit.

Inquire about interval history since the last visit.

PAST MEDICAL HISTORY

Illnesses

Exposures to harmful substances

Accidents or injuries

Hospitalizations or Surgeries

Medications (complete with dosages, frequency, and reason)

Allergies to medications or food (with reaction)

OTHER PEDIATRIC HISTORY

FEEDING HISTORY – EARLY AND MIDDLE CHILDHOOD / ADOLESCENCE

Appetite

Types of food/milk eaten and amounts

Parental attitudes toward eating

Difficulties or concerns with eating

OTHER PEDIATRIC HISTORY

DEVELOPMENTAL HISTORY & MILESTONES

General physical growth parameters throughout childhood (growth spurts)

Concerns with child meeting past developmental milestones

Sleeping patterns (day and night)

Any concerns with ritualistic behavior or habits

Discipline techniques used and effectiveness

School (academic achievements, social relationships, concerns)

Peer relationships (concerns, types)

Sexuality (interactions with opposite sex, knowledge of conception, pregnancy, differences in boys and girls, parental attitude toward sex education, dating patterns)

Personality (degree of independence, relationships with parents and siblings, imaginary friends, self-image)

Addresses the “Suicide” component of the HEADSS assessment.

Addresses the “Home” component of the HEADSS assessment.

Addresses the “Activities/Employment” component of the HEADSS assessment.

IMMUNIZATIONS

Current immunization status

Past reactions to immunizations

Parental attitude toward immunizations

FAMILY HISTORY

Medical history of grandparents

Medical history of parents

Medical history of siblings

Other general familial diseases

SOCIAL HISTORY

Other household members (relationship to patient and age)

Immediate family members not living in the household

Childcare arrangements

Financial resources of family

Childproofing and safety concerns around house (including gun safety)

Any recent changes/problems with living/family environments

Recent travel or relocation

Pets or exposure to animals

Drug use (family or patient)

Alcohol use (family or patient)

Tobacco use (family or patient)

Seatbelts/carseats/booster seats. Helmet use. Swimming pool at home?

Concerns for abuse

NP Student: Communication and Skills

Verbalizes necessary immunizations at this visit based on CDC recommendations (chart available to students)

Verbalizes anticipatory guidance with regard to AAP car seat / safety belt guidelines.

Verbalizes one additional component of age-appropriate anticipatory guidance according to Bright Futures Guidelines.

Properly charts the patient’s stature for age on the CDC growth chart.

Properly charts the patient’s BMI for age on the CDC growth chart.

Properly charts the patient’s weight for age on the CDC growth chart.

SOAP note TEMPLATE

SUBJECTIVE:

ID:

CC: “ “

HISTORY OF PRESENT ILLNESS (HPI):

PAST MEDICAL HISTORY

PAST MEDICAL PROCEDURES

MEDICATIONS

ALLERGIES

FAMILY HISTORY

SOCIAL HISTORY

-SEXUAL/REPRODUCTIVE

-TOBACCO USE/Vaping:

-ALCOHOL USE: social drinker

-DRUG USE:

-MARITAL HISTORY:

-OCCUPATION:

-EXERCISE/DIET:

-SLEEP/STRESS:

IMMUNIZATIONS

SPIRITUAL AFFILIATION

REVIEW OF SYSTEMS:

ONLY DOCUMENT WHAT YOU ASKED ABOUT

DO NOT copy and paste this list or you will have a high “Turn-It-In” score. Students should be able to reword and include only what they asked.

CONSTITUTIONAL: denies fever, chills, and loss of appetite, fatigue, or weight loss

EYES: denies blurred vision, scleral icterus, tunnel vision, discharge, pruritus, edema, and redness (date of last eye exam can go here)

EARS, NOSE, MOUTH/THROAT: denies hearing loss, tinnitus, vertigo, discharge, and earache, denies rhinorrhea, stuffiness, sneezing, and epistaxis, denies allergies, denies pain or difficulty swallowing (date of last dental exam can go here)

CARDIOVASCULAR: denies angina, palpitations, orthopnea, paroxysmal nocturnal dyspnea, edema, or dyspnea.

RESPIRATORY: Denies hemoptysis, wheezing, and shortness of breath, cough, or sputum production.

GASTROINTESTINAL: denies, dysphagia, constipation, abdominal pain, hemorrhoids. Reports rectal bleeding with bright red blood, rectal pain, and reflux and history of rectal cancer.

GENITOURINARY: denies urinary urgency, hesitancy, frequency, polyuria, dysuria, hematuria, incontinence, libido changes, and infection. Women: Denies menstrual changes, vaginal discharge, vaginal dryness or pain, or abnormal bleeding. Men: Denies scrotal pain, penis pain, masses, weak stream or erectile dysfunction

MUSCULOSKELETAL: denies stiffness, joint pain, joint swelling, muscle pain, or decreased ROM.

INTEGUMENTARY/BREAST: Denies pruritus, rashes, stria, lesions, wounds, nodules, tumors, eczema, excessive dryness and/or discoloration. Denies breast pain, soreness, lumps, or discharge.

NEURO: denies seizures, headaches, motor weakness, paresthesias, paralysis, memory loss

PSYCH: denies anxiety, depression, mood changes, body image problems, mania, binges, or suicidal thoughts

ENDOCRINE: Denies heat or cold intolerance, weight changes, polyuria, polydipsia, polyphagia, changes in hair, libido or sexual performance

HEMATOLOGIC/LYMPHATIC: Denies excessive bleeding, easy bruising, petechia. Denies enlarged, swollen, or tender lymph nodes

ALLERGY/IMMUNOLOGY: Denies drug/food/seasonal allergies, denies getting sick more frequently than others, or taking longer to recover

OBJECTIVE:

VITAL SIGNS: P: BP: RR: T: 97.8 SpO2 RA: Pain : /10

Ht : Wt : BMI:

PHYSICAL EXAM: GENERAL survey:

HEENT:

Head

Eyes

Ears

Nose

Throat

Mouth

·

HEART:

RESPIRATORY:

CHEST/BREASTS:

GI:

GU:

LYMPH:

MUSCULOSKELETAL/EXTREMITIES:

SKIN:

NEUROLOGIC:

PSYCHIATRIC:

ASSESSMENT:

Differential Diagnosis:

1. One possible dx with rationale on why you ruled out

2. Another

3. A third (minimum = three)

4. A fourth

FINAL DX: The chosen diagnosis from above

PLAN:

-Diagnostic plan (labs/xrays/EKG etc.)

-Treatment/Therapeutic Plan: Meds, treatments, diet/exercise/etc. recommendation

-Referrals

-Education

-F/U plan

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