week 5 pediatric soap note

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Home>Homework Answsers>Nursing homework helpWORKstudyAPA format, evidence based practice. Due in 24 hrs. Previous soap note and feedback from instructor provided.24 days ago08.06.202530Report issuefiles (2)PEDSSOAPNoteTemplateweek5.docxfeedbackfocusedWeek3-pedssoapnotetemplate1.docxPEDSSOAPNoteTemplateweek5.docxJ06.9 | Acute upper respiratory infection, unspecified
J30.9 | Allergic rhinitis, unspecifiedPatient 13 months old comes in with mom for complains of wet cough that started on 5/23 with decreased activity, voice changed and decreased appetite . Patient voice change ,activity level and appetite resolved. Patient started to have nasal congestion yesterday 5/28/25. Patient mom denies any fever, rash, signs of ear pain.
A: nasal congestion noted, ears TMs pearly clear BL,
throat not irritated, BL tonsils +1
RUL, RML, RLL, LUL, LLL lung fields clear
TX: Increase fluid intake over the counter ibuprofen to treat fever and body aches
F/U in 9 months for annual exam or PRN if symptoms worsenSubjective, Objective, Assessment, Plan (SOAP) NotesStudent name:Course:Patient name (initials only):Date: Time:Ethnicity:Age: Sex:SUBJECTIVECC:HPI:Medications:Past medical history:Allergies:Birth hx: (use only on well child visits):Immunizations:Hospitalizations:Past surgical history:Social history:Developmental Assessment: (include on well child visit only but may be necessary for problem focused notes)FAMILY HISTORYMother:MGM:MGF:Father:PGM:PGF:REVIEW OF SYSTEMSGeneral:Cardiovascular:Skin:Respiratory:Eyes:Gastrointestinal:Ears:Genitourinary/Gynecological:Nose/Mouth/Throat:Musculoskeletal:Breast: Heme/Lymph/Endo:Neurological:Psychiatry:OBJECTIVE (Document PERTINENT systems only, Minimum 3 for problem focused, all systems for well child exam)Weight: Height: BMI: BP: Temp: Pulse: Resp:(Insert plotted growth chart below on all well child soap notes)General appearance:Skin:HEENT:Cardiovascular:Respiratory:Gastrointestinal:Genitourinary:Musculoskeletal:Neurological:Psychiatric:Labs performed in office the day of visit:Diagnosis (must complete this section and explain how all differential diagnoses were ruled in or ruled out)Differential diagnoses:1. Diagnosis, (ICD 10 code and reference):2. Diagnosis, (ICD 10 code and reference):3. Diagnosis (ICD 10 code and reference):Diagnosis(ICD 10 code and reference):Plan/therapeutics/diagnostics;Education provided:CPT Code:Anticipatory guidance (well child visit only)References:feedbackfocusedWeek3-pedssoapnotetemplate1.docxThis file is too large to display.View in new windowfeedbackfocusedWeek3-pedssoapnotetemplate1.docxThis file is too large to display.View in new windowPEDSSOAPNoteTemplateweek5.docxJ06.9 | Acute upper respiratory infection, unspecified
J30.9 | Allergic rhinitis, unspecifiedPatient 13 months old comes in with mom for complains of wet cough that started on 5/23 with decreased activity, voice changed and decreased appetite . Patient voice change ,activity level and appetite resolved. Patient started to have nasal congestion yesterday 5/28/25. Patient mom denies any fever, rash, signs of ear pain.
A: nasal congestion noted, ears TMs pearly clear BL,
throat not irritated, BL tonsils +1
RUL, RML, RLL, LUL, LLL lung fields clear
TX: Increase fluid intake over the counter ibuprofen to treat fever and body aches
F/U in 9 months for annual exam or PRN if symptoms worsenSubjective, Objective, Assessment, Plan (SOAP) NotesStudent name:Course:Patient name (initials only):Date: Time:Ethnicity:Age: Sex:SUBJECTIVECC:HPI:Medications:Past medical history:Allergies:Birth hx: (use only on well child visits):Immunizations:Hospitalizations:Past surgical history:Social history:Developmental Assessment: (include on well child visit only but may be necessary for problem focused notes)FAMILY HISTORYMother:MGM:MGF:Father:PGM:PGF:REVIEW OF SYSTEMSGeneral:Cardiovascular:Skin:Respiratory:Eyes:Gastrointestinal:Ears:Genitourinary/Gynecological:Nose/Mouth/Throat:Musculoskeletal:Breast: Heme/Lymph/Endo:Neurological:Psychiatry:OBJECTIVE (Document PERTINENT systems only, Minimum 3 for problem focused, all systems for well child exam)Weight: Height: BMI: BP: Temp: Pulse: Resp:(Insert plotted growth chart below on all well child soap notes)General appearance:Skin:HEENT:Cardiovascular:Respiratory:Gastrointestinal:Genitourinary:Musculoskeletal:Neurological:Psychiatric:Labs performed in office the day of visit:Diagnosis (must complete this section and explain how all differential diagnoses were ruled in or ruled out)Differential diagnoses:1. Diagnosis, (ICD 10 code and reference):2. Diagnosis, (ICD 10 code and reference):3. Diagnosis (ICD 10 code and reference):Diagnosis(ICD 10 code and reference):Plan/therapeutics/diagnostics;Education provided:CPT Code:Anticipatory guidance (well child visit only)References:feedbackfocusedWeek3-pedssoapnotetemplate1.docxThis file is too large to display.View in new windowPEDSSOAPNoteTemplateweek5.docxJ06.9 | Acute upper respiratory infection, unspecified
J30.9 | Allergic rhinitis, unspecifiedPatient 13 months old comes in with mom for complains of wet cough that started on 5/23 with decreased activity, voice changed and decreased appetite . Patient voice change ,activity level and appetite resolved. Patient started to have nasal congestion yesterday 5/28/25. Patient mom denies any fever, rash, signs of ear pain.
A: nasal congestion noted, ears TMs pearly clear BL,
throat not irritated, BL tonsils +1
RUL, RML, RLL, LUL, LLL lung fields clear
TX: Increase fluid intake over the counter ibuprofen to treat fever and body aches
F/U in 9 months for annual exam or PRN if symptoms worsenSubjective, Objective, Assessment, Plan (SOAP) NotesStudent name:Course:Patient name (initials only):Date: Time:Ethnicity:Age: Sex:SUBJECTIVECC:HPI:Medications:Past medical history:Allergies:Birth hx: (use only on well child visits):Immunizations:Hospitalizations:Past surgical history:Social history:Developmental Assessment: (include on well child visit only but may be necessary for problem focused notes)FAMILY HISTORYMother:MGM:MGF:Father:PGM:PGF:REVIEW OF SYSTEMSGeneral:Cardiovascular:Skin:Respiratory:Eyes:Gastrointestinal:Ears:Genitourinary/Gynecological:Nose/Mouth/Throat:Musculoskeletal:Breast: Heme/Lymph/Endo:Neurological:Psychiatry:OBJECTIVE (Document PERTINENT systems only, Minimum 3 for problem focused, all systems for well child exam)Weight: Height: BMI: BP: Temp: Pulse: Resp:(Insert plotted growth chart below on all well child soap notes)General appearance:Skin:HEENT:Cardiovascular:Respiratory:Gastrointestinal:Genitourinary:Musculoskeletal:Neurological:Psychiatric:Labs performed in office the day of visit:Diagnosis (must complete this section and explain how all differential diagnoses were ruled in or ruled out)Differential diagnoses:1. Diagnosis, (ICD 10 code and reference):2. Diagnosis, (ICD 10 code and reference):3. Diagnosis (ICD 10 code and reference):Diagnosis(ICD 10 code and reference):Plan/therapeutics/diagnostics;Education provided:CPT Code:Anticipatory guidance (well child visit only)References:feedbackfocusedWeek3-pedssoapnotetemplate1.docxThis file is too large to display.View in new window12Bids(51)PROVEN STERLINGDr. Ellen RMMathProgrammingDr. Aylin JMDr. Sarah BlakeDr Michelle Ellaabdul_rehman_STELLAR GEEK A+ProWritingGuruYoung NyanyaProf. TOPGRADEfirstclass tutorProf Double Rsherry proffnicohwilliamTutor Cyrus KenIsabella HarvardMUSYOKIONES A+Dr ClovergrA+de plusShow All Bidsother Questions(10)short paper with referencesBiggest Challenges Facing Organizations in Next Twenty Years*****Already A++ Rated Tutorial Use as Guide Paper*****Homework Assignment 4 – ONE PAGEPCN-531 Week 7 Smith Family Case Study Essay, Preparation123ENG 102 Victorian Cultural StudyAssignment 3: Performance Managementjava programming 6SPAN110Rubric_LT Paper-Week _2Project: Presenting to the Board of Directors (BoD)

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