pediatric soap notes
- 0Sep 17, '06 by twalkerI am having such a hard time writing my soap note for class. I am a graduate student in the APN program. We have to write several soap notes a semester. Do anyone know of a web site that has a good example of how these suppose to flow correctly. Help please. Thank you
- 0Oct 1, '06 by adria37You might try here for a general template.
- 0Oct 2, '06 by traumaRUs, MSN, APRN, CNS AdminHere is the template I've used:
S: Subjective - what patient says
O: Objective - What you observe/exam:
labs, Neuro, Lungs, Heart
Incision and wound appearance, I & O
Diet - tolerating??
A: Assessment - diagnosis and POD # (Post-op day or hospital day)
P: Plan ...
- 0Oct 19, '06 by adria37Okay I get what you are asking, I think.
Subjective- Informant, health history, concerns, past medical history (injury or illness since last visit, medications, allergies, nutrition, feeding, elimination, sleep, safety practices, health habits (tv, exercise) discipline methods, family profile home situation, support system, employment any parental concerns *subjective* things reported/told to you
Objective- Physical exam VS head circ, height weight, general appearance parent child interaction developmental tests lab tests *objective* things you observe.
Assessment- Diagnosis (can be well baby, well child check, 2 year old exam, and so on)
Plan- Include health maintenance, follow up, pt education, diagnostic tests, consultations.
Hope that helps :wink2: