Well-child SOAP Note Format      Demographic Data  · Age, and gender (must be HIPAA compliant) 

Well-child SOAP Note Format     

Demographic Data 

· Age, and gender (must be HIPAA compliant) 

Subjective 

· ___-day/week old infant/child accompanied by ___________ and here for a routine well-child/baby check (and vaccines). Any parental concerns/ questions today? 

· Interval Events/History: 

· Nutrition: 

· Elimination: 

· Sleep: 

· Medications: 

· Allergies: 

· Past Medical 

·

· Pregnancy and delivery? 

· Surgeries, hospitalizations, or serious illnesses to date? 

· Immunizations? 

· Development: (describe as applicable to age) 

·

· Gross motor: 

·

· Fine motor: 

· Cognitive: 

· Social/Emotional: 

· Communication: 

· Social History: 

· Smoking in the home? 

· Family life/structure/dynamics? Primary caregivers? 

· Stressors? 

·  Family History: 

Objective 
(Should be a thorough head to toe assessment) 

· Vital Signs/growth measurements (weight, length, head circumference, BMI, BP, HR, etc. if applicable) 

·

· Physical findings listed by body systems, not paragraph form. 

· Highlight abnormal findings 

· Growth Chart Percentages: if applicable 

· Labs/Studies: if applicable 

 
Assessment  

· Well-child visit ICD10 code(s) 

Plan 

· Vaccines today: 

· Anticipatory guidance (discussed or covered in the visit)? 

· Health Maintenance 

· Return precautions? 

Share This Post

Email
WhatsApp
Facebook
Twitter
LinkedIn
Pinterest
Reddit

Order a Similar Paper and get 15% Discount on your First Order

Related Questions

  Follow these guidelines when completing each component of the Collaboration Café. Contact your course faculty if you have questions.  Include the

  Follow these guidelines when completing each component of the Collaboration Café. Contact your course faculty if you have questions.  Include the following sections:  Application of Course Knowledge:  Reflect on your learning experience. Which concepts stood out to you and made an impact?  How do you envision using the concepts learned in this

The Centers for Medicare and Medicaid Services (CMS) publishes a list of health care-acquired conditions (HACs) that reasonably could have been prevent

The Centers for Medicare and Medicaid Services (CMS) publishes a list of health care-acquired conditions (HACs) that reasonably could have been prevented through the application of risk management strategies. What actions has your health care organization (or have health care organizations in general) implemented to manage or prevent these “never

need help with a developing nursing course assignment Home / My courses / 2025_APR_SIMPATH_BSN436-SIM_1139225 / Module Two: Internal and

need help with a developing nursing course assignment Home / My courses / 2025_APR_SIMPATH_BSN436-SIM_1139225 / Module Two: Internal and External Environmental Forces that Affect Critical Thinking and Patient Centered Care / Assignment 1 Instructions, Rubric and Submission area 2025_APR_SIMPATH_BSN436-SIM_Developing Nursing Practice_2 Assignment 1 Instructions, Rubric and Submission area To do:

pls read insturctions attached  Genogram Family Analysis This scholarly paper is an interpretive analysis of the comprehensive genogram

pls read insturctions attached  Genogram Family Analysis This scholarly paper is an interpretive analysis of the comprehensive genogram illustration which highlights trends in family relationships, marital status, family issues, family patterns of mental illness, and substance abuse. Develop a scholarly paper that addresses the following criteria: 1. Complete a 5