Pediatric SOAP note for atopic dermatitis

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])