CONPH NSG6435 Subjective, Objective, Assessment, Plan (SOAP) Notes Nursing Writing Services Soap Note Samples

  

Patient Name: (Initials ONLY): J. S

Date: April 30, 2024

Time:

Ethnicity: Hispanic

Age: 3

Sex: F

SUBJECTIVE (must complete this section)

CC: Parental concern about child's recurring fevers.

HPI: J.S, Patient presented with intermittent fevers over the past week, highest recorded temperature was 102°F. No other associated symptoms noted. Parents administered acetaminophen for fever control.

Medications: Acetaminophen for fever

Previous Medical History: None

Developmental History: Developmentally appropriate for age

Allergies: None

Medication Intolerances: None

Chronic Illnesses/Major traumas: None

Immunizations: Up to date

Hospitalizations/Surgeries: None

Health Promotion/Health Maintenance: Routine pediatrician visits maintained.

Nutrition/Diet: Balanced diet reported by parents.

Exercise/Regimen: None

Tobacco/Alcohol/Vaping/Illicit Drug Use or Exposure: None

Safety Measures: Appropriate car seat use reported.

Screening exams: Routine pediatric visits

FAMILY HISTORY (must complete this section)

M: Healthy

MGM: Hypertension

MGF: None

F: Healthy

PGM: Diabetes

PGF: None

Social History: Lives with parents in a smoke-free environment.

REVIEW OF SYSTEMS (must complete this section)

General: No weight loss or fever reported

Cardiovascular: No palpitations or cyanosis

Skin: No rashes or lesions

Respiratory: No cough or shortness of breath

Eyes: No redness, discharge, or visual disturbances

Gastrointestinal: No vomiting, diarrhea, or constipation

Ears: No ear pain or discharge

Genitourinary/Gynecological: No urinary frequency, urgency, or dysuria

Nose/Mouth/Throat: No congestion, runny nose, or sore throat

Musculoskeletal: No joint pain or swelling

Breast: N/A

Neurological: No seizures, tremors, or abnormal movements

Heme/Lymph/Endo: No bruising or swelling of lymph nodes

Psychiatric: No mood disturbances or behavioral changes

OBJECTIVE (Document PERTINENT systems only, Minimum 3)

Weight: 15kg

Height: 95cm

BMI: 16.6

BP: 120/80 mmHg

Temp: 37°C

Pulse: 100 bpm

Resp: 20 bpm

SPO2%:93%

General Appearance: Well-nourished, interactive child.

Skin: No rashes or lesions

HEENT: Head: Normocephalic, atraumatic; Eyes: Pupils equal, round, reactive to light; no discharge or redness; Ears: Tympanic membranes intact bilaterally; Nose: Nasal mucosa pink, no discharge

Throat: Oropharynx pink, moist

Cardiovascular: Heart sounds regular, no murmurs

Respiratory: Respiratory rate within normal limits, lungs clear to auscultation bilaterally

Gastrointestinal: Abdomen soft, non-tender, no masses or organomegaly

Breast: N/A

Genitourinary: Diaper dry, no signs of urinary tract abnormalities

Musculoskeletal: Extremities symmetric, full range of motion

Neurological: Alert and responsive, normal tone and reflexes

Psychiatric: Not applicable

Diagnostic Studies: None

Special Tests: None