Submit a Well-child SOAP note for grading. You must use an actual patient from your clinical practicum.
Use the format below for your SOAP note as a reference and add/edit as needed depending on the age of the child/baby.
https://www.healthychildren.org/English/family-life/health-management/Pages/Well-Child-Care-A-Check-Up-for-Success.aspx

https://www.cdc.gov/vaccines/parents/visit/vaccination-during-COVID-19.html

https://www.aap.org/en/practice-management/bright-futures
Subjective, Objective, Assessment, Plan (SOAP) Notes
Student name:
Patient name (initials only):
Ethnicity:
Course:
Date:
Age:
Time:
Sex:
SUBJECTIVE
CC:
HPI:
Medications:
Past medical history:
Allergies:
Birth hx: (use only on well child visits):
Immunizations:
Hospitalizations:
Past surgical history:
Social history:
Developmental Assessment: (include on well child visit only but may be necessary for problem
focused notes)
FAMILY HISTORY
Mother:
MGM:
MGF:
Father:
PGM:
PGF:
REVIEW OF SYSTEMS
Cardiovascular:
Respiratory:
Gastrointestinal:
Genitourinary/Gynecological:
Musculoskeletal:
Neurological:
Psychiatry:
OBJECTIVE (Document PERTINENT systems only, Minimum 3 for problem focused, all systems for
well child exam)
Weight:
Height:
BMI:
BP:
Temp:
Pulse:
Resp:
General:
Skin:
Eyes:
Ears:
Nose/Mouth/Throat:
Breast: Heme/Lymph/Endo:
(Insert plotted growth chart below on all well child soap notes)
General appearance:
Skin:
HEENT:
Cardiovascular:
Respiratory:
Gastrointestinal:
Genitourinary:
Musculoskeletal:
Neurological:
Psychiatric:
Labs performed in office the day of visit:
Diagnosis (must complete this section and explain how all differential diagnoses were ruled in or
ruled out)
Differential diagnoses:
Diagnosis (ICD 10 code and reference):
1. Diagnosis, (ICD 10 code and reference):
2. Diagnosis, (ICD 10 code and reference):
3. Diagnosis (ICD 10 code and reference):
Plan/therapeutics/diagnostics;
Education provided:
CPT Code:
Anticipatory guidance (well child visit only)
References: