[Solved] well child wk4

Assignment Prompt & Instructions

– a year ago

**files (1)**

– ## wellchildsoapnotetemplate.docx

**## wellchildsoapnotetemplate.docx**

**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?

**## wellchildsoapnotetemplate.docx**

**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?