Well-child SOAP Note Format Demographic Data Age, and gender (must be HIPAA compliant) Subjective ___-day/week old infant/child accompanied by ___________ and here for a routine well-child/baby check (and vaccines). Any parental concerns/ questions today? Interval Events/History: Nutrition: Elimination: Sleep: Medications: Allergies: Past Medical Pregnancy and delivery? Surgeries, hospitalizations, or serious illnesses to date? Immunizations? Development: (describe as applicable to age) Gross motor: Fine motor: Cognitive: Social/Emotional: Communication: Social History: Smoking in the home? Family life/structure/dynamics? Primary caregivers? Stressors? Family History: Objective (Should be a thorough head to toe assessment) Vital Signs/growth measurements (weight, length, head circumference, BMI, BP, HR, etc. if applicable) Physical findings listed by body systems, not paragraph form. Highlight abnormal findings Growth Chart Percentages: if applicable Labs/Studies: if applicable Assessment Well-child visit ICD10 code(s) Plan Vaccines today: Anticipatory guidance (discussed or covered in the visit)? Health Maintenance Return precautions?
Well-child SOAP Note Format Demographic Data Age, and gender (must be HIPAA comp
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