Pediatric Soap Notes Worksheet

Create 10 PEDIATRIC ONLY (birth to 18 years old) Soap notes. Avoid repeating diagnosis. This needs to be from an FNP new perspective. Include a variety of preventive visits,acute, chronic, and wellness disorders annual exam pertaining only to this population.Include developmental appropriate stages. Every soap note needs a diagnosis and therapeutic section must have medications and full prescribing instructions specifically for the pediatric population. Include the patient’s weight.
Documentation Requirements
Must Include
Patient Demographics Section:
Age
Race
Gender
 Clinical Information Section:
Time with Patient
o Reason for visit
o Chief Complaint
o Social Problems Addressed
 Medications Section:
o # OTC Medications taken regularly
o # Prescriptions currently prescribed
o # New/Refilled Prescriptions This Visit
 ICD 10 Codes Category:
o Include for each diagnosis addressed at the visit
 CPT Billing Codes Category:
o Include Evaluation and management code
o Provider procedure codes (pap smear, destruction of lesion, sutures, etc.)
 Other Questions About This Case Category:
o Age Range
o Patient type
o HPI
o Patients Primary Language
o Did you chart on the patient record?
o Discussed Management with the Preceptor Handled Visit Independently
o Preceptor Present During Visit
 Clinical Notes Category :
PLEASE follow this format
ChiefComplaint: “***”
DIAGNOSIS: must have
PLAN:
Diagnostics:
Therapeutics:include full prescribing information safe dosing for pediatrics include weight
Education: Include (Developmental Stage guidance)
Consultation/Collaboration:

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