week 7 focused soap note

PEDS SOAP NOTE PEARLS

 

· HPI – always include assessment of diet, activity, elimination, sleep

· If has temp always document how temp was take- oral, axilla etc and what was last temp

· If had any meds get name, dose, last time given

· Ensure to include ALL aspects of OLDCARTS

 

· PE

· Every exam WCC or focused should include a skin assessment. Skin intact to thorax, bilateral UE and LE, no bruising, ecchymosis of skin tears noted.

· Include completes assessment for HEENT

· Head- ensure to examine fontanelles and document if open/closed

· Eyes-ensure to document complete assessment

· Ears-ensure to include cones of light exam

· Nose-ensure to include bilateral nare exam

· Sinus- ensure to include complete sinus exam

· Mouth- ensure to include buccal mucosa, dentition

· Throat- ensure complete exam

· Tonsil- ensure proper grading using tonsil scale

· Lymph nodes-document names of all lymph nodes head and neck and their assessment

· Cardio- ensure have S1, S2, no M/R/G

· Lungs- CTA bilateral UL/LL/laterally, anterior and posterior

· MSK- ensure to document proper strength scale 5+/5+, etc

· Reflexes- ensure to document proper scale 2+/2+, etc

 

· Assessment

· Need to provide rationale for all diff dx and final dx- how were they ruled in/out

 

· Plan

· Need detailed patient education- saying educated oh healthy diet not enough- need specifics- exactly what should their diet include

· Ensure to have ER precautions and specifics of when the patient should follow-up and why

· Anticipatory guidance should be included in all WCC- use Bright Futures resources

· All medication should include education on medication side effects

· All WCC need to have growth chart properly documented and plotted