06.9 | Acute upper respiratory infection, unspecified J30.9 | Allergic rhinitis, unspecified
Patient 13 months old comes in with mom for complains of wet cough that started on 5/23 with decreased activity, voice changed and decreased appetite . Patient voice change ,activity level and appetite resolved. Patient started to have nasal congestion yesterday 5/28/25. Patient mom denies any fever, rash, signs of ear pain. A: nasal congestion noted, ears TMs pearly clear BL, throat not irritated, BL tonsils +1 RUL, RML, RLL, LUL, LLL lung fields clear TX: Increase fluid intake over the counter ibuprofen to treat fever and body aches F/U in 9 months for annual exam or PRN if symptoms worsen
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)
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| 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) |
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| 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:
1. Diagnosis, (ICD 10 code and reference):
2. Diagnosis, (ICD 10 code and reference):
3. Diagnosis (ICD 10 code and reference): |
Diagnosis (ICD 10 code and reference): |
| Plan/therapeutics/diagnostics; | |
| Education provided: | |
| CPT Code:
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| Anticipatory guidance (well child visit only) |
References: