Pediatric SOAP Note

Pediatric SOAP Note
Pediatric SOAP Note
Sex: Age/DOB/Place of Birth:
SUBJECTIVE Historian: Present Concerns/CC: Reason given by the patient for seeking medical care “in quotes” Child Profile: (Sexual History (If appropriate); ADLs (age appropriate); Safety Practices; Changes in daycare/school/after-school care; Sports/physical activity; Developmental Hx) HPI: (must include all components) Medications: (List with reason for med ) PMH: Allergies: Medication Intolerances: Chronic Illnesses/Major traumas: Hospitalizations/Surgeries: Immunizations: Family History (Please identify all immediate family) Social History Education level, occupational history, current living situation/partner/marital status, substance use/abuse, ETOH, tobacco, and marijuana. Safety status ROS General
Cardiovascular
Skin
Respiratory
Pediatric SOAP Note
Eyes
Gastrointestinal
Ears
Genitourinary/Gynecological
Nose/Mouth/Throat
Musculoskeletal
Breast
Neurological
Heme/Lymph/Endo
Psychiatric
OBJECTIVE (plot height/weight/head circumference along with noting percentiles) Attach growth chart Weight
Temp BP
Height
Pulse Resp
General Appearance and parent?child interaction
Skin HEENT Cardiovascular Respiratory Gastrointestinal Breast Genitourinary
Pediatric SOAP Note
*ALL references must be Evidence Based (EB)
Musculoskeletal Neurological Psychiatric In-house Lab Tests – document tests (results or pending)
Pediatric/Adolescent Assessment Tools (Ages & Stages, etc) with results and rationale For adolescents (HEADSSSVG Assessment)
Diagnosis ? Include at least three differential diagnoses with ICD-10 codes. (Includes Primary dx and 2 differentials) ? Document Evidence based Rationale for ROS and each differential with pertinent positives and
negatives ? Primary diagnosis
? Is #1 on list of differentials ? Evidence for primary diagnosis should be supported in the Subjective and Objective exams.
PLAN including education
? Plan: Treatment plan should be for the Primary Diagnosis and based on EB literature. ? Include EB rationale for all aspects of your treatment plan:
? Vaccines administered this visit ? Vaccine administration forms given ? Medication-amounts and mg/kg for medications ? Laboratory tests ordered ? Diagnostic tests ordered ? Patient education including preventive care and anticipatory guidance ? Non-medication treatments ? Follow-up appointment with detailed plan of f/u
Basics of SOAP Notes
First, consider why you’re writing this SOAP note: who will it be read by, and what information should it convey?
The American Speech-Language-Hearing Association (ASHA) suggests that clinical notes be detailed enough that another SLP could read them and understand your therapy process well enough to continue therapy where you left off.
Here are some good SOAP note samples for each section:
S stands for subjective.
Your feelings about the patient’s consciousness, mood, and conduct.
Direct quotes from the patient can also be included.
This is an excellent location to discuss a patient’s feelings regarding their speech development or therapy in general.
EXAMPLE: Throughout the discussion, Suzy appeared alert and attentive.
Suzy commented “I was looking forward to speech all week!” according to her mother, and Suzy’s teacher noted she had been able to comprehend Suzy better in the last week.
O is for Objective.
Measurable data (for example, data), such as percentages and which goals and objectives were met.
You might also mention the activity that was utilized to gather this information.
Suzy used a worksheet with 10 /k/ vs. /t/ minimum pairings, two verbal reminders (e.g., “Is that Tar or Kar?”), and a mirror for self-correction to generate /k/ at the beginning of words with 70% accuracy.
A: Evaluation
Your take on the meeting.
Compare the patient’s performance over sessions if possible.
EXAMPLE: During the past session, Suzy’s correct production of /k/ in beginning position increased from 60% in imitation and with a visual aid to 70% during today’s session.
The absence of a visual aid (a depiction of a mouth making the /l/ sound) had no effect on performance.
P is for Plan.
Outline the treatment plan and therapy goals for the following session.
Include potential activities, reinforcement/cuing strategies, any revisions to objectives, and any homework you send home.
EXAMPLE: Suzy’s initial /k/ production continues to improve.
At the next session, fade the cues and the initial model of the sound for the initial /k/.
Suzy’s mother was given three minimal pair worksheets from the XYZ book to complete.
Check out this free SOAP note package, which contains a template, checklist, extra SOAP note examples, and 7 Documentation Tips.