Focused Soap Note -Pediatric

Review the Focused Note Checklist provided in this week’s Learning Resources and consider how you will
develop your Focused Note for this week’s Assignment.
Use the Focused SOAP Note Template and the example found in the Learning Resources for this week to
complete this Assignment.
Select an adolescent patient that you examined during the last 3 weeks. With this patient in mind, address the
following in a Focused Note.
Subjective: What details did the patient or parent provide regarding the personal and medical history? Include
any discrepancies between the details provided by the child and details provided by the parent as well as
possible reasons for these discrepancies.
Objective: What observations did you make during the physical assessment? Include pertinent positive and
negative physical exam findings. Describe whether the patient presented with any growth and development or
psychosocial issues.
Assessment: What were your differential diagnoses? Provide a minimum of three possible diagnoses. List them
from highest priority to lowest priority and include their ICD-10 code for the diagnosis. What was your primary
diagnosis and why?
Plan: What was your plan for diagnostics and primary diagnosis? What was your plan for treatment and
management? Include pharmacologic and non-pharmacologic treatments, alternative therapies, and follow-up
parameters as well as a rationale for this treatment and management plan.
Reflection notes: What was your “aha” moment? What would you do differently in a similar patient evaluation?
Please use the focused note template provided for the assignment

Leave a Reply

Your email address will not be published. Required fields are marked *