Pediatric Soap Notes Worksheet

Create 10 PEDIATRIC ONLY (birth to 18 years old) Soap notes. Avoid repeating diagnosis. This needs to be from an FNP new perspective. Include a variety of preventive visits,acute, chronic, and wellness disorders annual exam pertaining only to this population.Include developmental appropriate stages. Every soap note needs a diagnosis and therapeutic section must have medications and full prescribing instructions specifically for the pediatric population. Include the patient’s weight.

Documentation Requirements

Must Include

• Patient Demographics Section:
• Age
• Race
• Gender
•  Clinical Information Section:
• Time with Patient
  o Reason for visit
  o Chief Complaint
  o Social Problems Addressed
•  Medications Section:
  o # OTC Medications taken regularly
  o # Prescriptions currently prescribed
  o # New/Refilled Prescriptions This Visit
•  ICD 10 Codes Category:
  o Include for each diagnosis addressed at the visit
•  CPT Billing Codes Category:
  o Include Evaluation and management code
  o Provider procedure codes (pap smear, destruction of lesion, sutures, etc.)
•  Other Questions About This Case Category:
• o Age Range
• o Patient type
  o HPI
  o Patients Primary Language
  o Did you chart on the patient record?
  o Discussed Management with the Preceptor Handled Visit Independently
  o Preceptor Present During Visit

 Clinical Notes Category :

PLEASE follow this format

ChiefComplaint: “***”
DIAGNOSIS: must have
PLAN:

Diagnostics:
Therapeutics:include full prescribing information safe dosing for pediatrics include weight
Education: Include (Developmental Stage guidance)

Consultation/Collaboration:

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