Pediatric SOAP NOTE
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Case for soap note: 14 year old Male
Patient is a 14 year old who came in today complaining of sore throat for 3 days. Patient denies any fever, cough or SOB at this time. Lung sounds clear to auscultation, erythematous throat, tonsils +1 BL, no cervical lymphedema noted during assessment. Patient instructed to Gargling with Salt Water at least twice a day for sore throat. Tylenol and Motrin over the for sore throat and if fever. If symptoms worsen or persist to call back the office.
J02.9 | Acute pharyngitis, unspecified
Subjective, Objective, Assessment, Plan (SOAP) Notes
Student name:
Course:
Patient name (initials only):
Date: Time:
Ethnicity:
Age: 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
General:
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)
APA format. use evidence based practice and CDC guidelines
