Pediatric SOAP note for atopic dermatitis

you are going to write a pediatric SOAP note about atopic dermatitis. PT’s initials: C.J. is a 16 year old white male that goes to the pediatric clinic with his mom with complaints of a dried scaly gray patch on the inner right side of his leg. I am attaching an example of a SOAP note and the way it should be written. You are going to use at least 6 references and in text citations for diagnosis ( primary), differential diagnosis, Education, anticipatory guidance. I am attaching the template so you can develop the SOAP note. Note that pediatric SOAP notes focus on developmental stages of life as well.

SOAP NOTE TEMPLATE Review the Rubric for more Guidance
Demographics
Chief Complaint (Reason for seeking health care)
History of Present Illness (HPI)
Allergies
Review of Systems (ROS)	General: HEENT: Neck: Lungs: Cardio Breast: GI: M/F genital: GU: Neuro Musculo: Activity: Psychosocial: Derm: Nutrition: Sleep/Rest: LMP: STI Hx:
Vital Signs
Labs
Medications
Past Medical History
Past Surgical History
Family History
Social History
Health Maintenance/ Screenings
Physical Examination	General: HEENT: Neck: Lungs: Cardio Breast: GI: M/F genital: GU: Neuro Musculo: Activity: Psychosocial: Derm:
Diagnosis
Differential Diagnosis
ICD 10 Coding
Pharmacologic treatment plan
Diagnostic/Lab Testing
Education
Anticipatory Guidance
Follow up plan
Prescription	See Below (scroll down)
References
Grammar

 

 

 

EA#: 101010101 STU Clinic LIC# 10000000

Tel: (000) 555-1234 FAX: (000) 555-12222

Patient Name: (Initials)______________________________ Age ___________ Date: _______________ RX ______________________________________ SIG: Dispense: ___________ Refill: _________________ No Substitution     Signature:____________________________________________________________

 

 

 

Signature (with appropriate credentials):_____________________________________

 

References (must use current evidence-based guidelines used to guide the care [Mandatory])