pediatric soap notes

[twalker]

I 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

[adria37]

You might try here for a general template.

http://med.fsu.edu/informatics/Progress%20Note%20Template%20Guidelines.pdf

[traumaRUs, MSN, APRN]

Here is the template I've used:

SOAP Note

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 ...

[twalker]

Thanks a lot for the help. I really need it, peds it not exactly my strong subject.

[traumaRUs, MSN, APRN]

The soap note for peds should be like an adult note only with pedi-specific info. (At least it was in my APN program). GOod luck.

[fluffhead]

This is pretty basic, but I still need guidance...

So obviously the newborns have no subjective data - what do we place there instead? Even some peds would be hard to pin down on the S, right?

[adria37]

Okay 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: