COMPREHENSIVE SOAP NOTE TEMPLATE
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School
South University, Tampa *
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Course
6430
Subject
Health Science
Date
Dec 6, 2023
Type
docx
Pages
3
Uploaded by bwells91
BREANNA WELLS BSN, RN
PEDIATRIC COMPREHENSIVE SOAP NOTE
DEMOGRAPHICS
PATIENT INITIALS
AGE
SEX
RACE/ETHNICITY
HISTORIAN
SUBJECTIVE
CC
HPI
PAST HISTORY
PMH
PSH
GYN HX
PSYCHIATRIC
HISTORY
FAMILY HISTORY/SOCIAL HISTORY
FAMILY HISTORY
SOCIAL HISTORY
DEVELOPMENT
MEDICATION RECONCILIATION/ REVIEW
MEDICATION AND
INDICATIONS
ALLERGIES/ IMMUNIZATIONS
ALLERGIES
IMMUNIZATIONS
HEALTH PROMOTION/ MAINTENANCE
NURTITION/DIET
EXERCISE REGIMEN
TOBACCO/ALCOHOL
/ ILLICIT DRUG USE
SCREENINGS/EXAMS
REVIEW OF SYSTEMS
CONSTITUTIONAL/
GENERAL
EYES
EARS/NOSE/
MOUTH/THROAT
CARDIOVASCULAR
RESPIRATORY
GI/ABDOMEN
GU
MUSCULOSKELETAL
INTEGUMENTARY
BREANNA WELLS BSN, RN
NEUROLOGICAL
PSYCHIATRIC
ENDOCRINE
HEMATOLOGIC/
LYMPHATIC
ALLERGIC/
IMMUNOLOGIC
OBJECTIVE
VS
HR:
BP:
RR:
O2:
HEIGHT:
WEIGHT:
BMI:
PHYSICAL EXAM
CONSTITUTIONAL/
GENERAL
EYES
EARS/NOSE/
MOUTH/THROAT
NECK
RESPIRATORY
CARDIOVASCULAR
CHEST/THORAX
GI/ABDOMINAL
GU
LYMPHATIC
MUSULOSKELETAL
INTEGUMENT/ SKIN
NEUROLOGIC
PSYCHIATRIC
RESULTS REVIEWED
ASSESSMENT
DX & ICD 10
DDX & ICD 10
PLAN
PHARMACOLOGICAL
TREATMENTS
NON-
PHARMACOLOGICAL
TREATMENTS
REFERRALS
LABS/DIAGNOSTICS/
ORDERED
EDUCATION
PROVIDED
FOLLOW UP/
DISPOSITION
BREANNA WELLS BSN, RN
References
Anzilotti, A. W. (Ed.). (2019, February).
Dealing with stress in sports (for teens)
. KidsHealth.
Retrieved April 17, 2022, from https://kidshealth.org/en/teens/sports-pressure.html
Centers for Disease Control and Prevention. (2020, March 19).
Promoting healthy behaviors
.
Centers for Disease Control and Prevention. Retrieved April 17, 2022, from
https://www.cdc.gov/healthyschools/healthybehaviors.htm
Division of Nutrition, Physical Activity, and Obesity, National Center for Chronic Disease
Prevention and Health Promotion. (2021, September 28).
BMI Calculator Child and teen
.
Centers for Disease Control and Prevention. Retrieved April 17, 2022, from
https://www.cdc.gov/healthyweight/bmi/result.html?
&method=english&gender=f&age_y=16&age_m=4&hft=5&hin=9&twp=103
Gavin, M. L. (Ed.). (2022, February).
Sports physicals (for teens) - nemours kidshealth
.
KidsHealth. Retrieved April 17, 2022, from https://kidshealth.org/en/teens/sports-
physicals.html
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