Soap Note

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Select a pediatric patient that presented to the clinic, who you examined as a nurse practitioner/ provider during the last 4 weeks. With this patient in mind, address the following in a SOAP 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. 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 to the clinic , 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?

References

•Burns, C. E., Dunn, A. M., Brady, M. A., Starr, N. B., & Blosser, C. G. (2013). Pediatric primary care (5th ed.). Philadelphia, PA: Elsevier.

◦Chapter 34, “Genitourinary Disorders” (pp. 809–843)

◦Chapter 35, “Gynecologic Disorders” (pp. 844–876)

American Academy of Pediatrics, Subcommittee on Urinary Tract Infection, Steering Committee on Quality Improvement and Management. (2011). Urinary tract infection: Clinical practice guideline for the diagnosis and management of the initial UTI in febrile infants and children 2 to 24 months. Pediatrics, 128(3), 595–610. Retrieved from http://pediatrics.aappublications.org/content/128/3/595.full?sid=cc35023c-502d-474a-9856-bfb5e38eed54

•Cox, A. M., Patel, H., & Gelister, J. (2012). Testicular torsion. British Journal of Hospital Medicine, 73(3), C34–C36. Retrieved from the Walden Library Databases.