Submit a Well-child SOAP note for grading. You must use an actual patient from your clinical practicum.
Use the format below for your SOAP note as a reference and add/edit as needed depending on the age of the child/baby
You may refer to the following websites for additional information on the recommended schedule:
https://www.healthychildren.org/English/family-life/health-management/Pages/Well-Child-Care-A-Check-Up-for-Success.aspx
https://www.cdc.gov/vaccines/parents/visit/vaccination-during-COVID-19.html
https://www.aap.org/en/practice-management/bright-futures
Patient is a 11 year old female patient coming in to clinic for her wellness check up.
Please complete the entire template in depth and make up information that can relate.
Subjective, Objective, Assessment, Plan (SOAP) Notes
Student name:
Patient name (initials only):
Ethnicity:
Course:
Date:
Age:
Time:
Sex:
SUBJECTIVE
CC:
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 HISTORY
Mother:
MGM:
MGF:
Father:
PGM:
PGF:
REVIEW OF SYSTEMS
Cardiovascular:
Respiratory:
Gastrointestinal:
Genitourinary/Gynecological:
Musculoskeletal:
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:
General:
Skin:
Eyes:
Ears:
Nose/Mouth/Throat:
Breast: Heme/Lymph/Endo:
(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:
Diagnosis (ICD 10 code and reference):
1. Diagnosis, (ICD 10 code and reference):
2. Diagnosis, (ICD 10 code and reference):
3. Diagnosis (ICD 10 code and reference):
Plan/therapeutics/diagnostics;
Education provided:
CPT Code:
Anticipatory guidance (well child visit only)
References:
