Pediatric SOAP Note
Choose two of the pediatric scenarios.
Document an episodic S and O note for each pediatric patient you chose. Include all components of the subjective section that are pertinent. You may fabricate any pertinent information that is not given in the scenario to make it complete, but do not change the intent of the scenario. For example, do not fabricate additional diagnoses or symptoms that may lead to a different diagnosis.
Write a 700-word paper for each patient in which you document the SO portion of a SOAP note and address the following:
- Documentation of all elements of a physical exam using appropriate terminology
- A thorough subjective report, including a list of at least five open-ended questions relevant to the chief complaint you would ask during the HPI exam
- Use descriptive language familiar to the patient
- Include the rationale for asking each question
- Explain why they are appropriate and align to the chief complaint, and include academic resources that support your explanation
- A symptom analysis that identifies all the pertinent positives and pertinent negatives from the HPI (Bates’ Guide to Physical Examination and History Taking, pp. 9, 11, and 80)
- Click the Scenario tab above for a link to the textbook.
- An objective report that documents all relevant specialty tests during the physical exam
- Include at least three rationales for the specialty test
- Include observations you made during the patient interview
- Identify the appropriate ICD-10 codes and E&M codes
- Identify at least two barriers to quality health care the patient might experience based on the interview (e.g., cultural, linguistic, economic, previous conditions, etc.).
- Explain how the FNP can address these barriers to improve the quality of care the patient receives.
- Include academic evidence that supports your explanation.
Include a minimum of two peer reviewed academic sources to support your answers, one of which may be your textbook.
Format your paper according to APA guidelines.