Scenario: Mandy is a 6-year-old who has been brought in by her new foster mother for a well-child exam. The foster mother states that Mandy was removed from her home due to neglect and physical and sexual abuse.
Incorporate these questions in the SOAP note…..
What types of abnormal behaviors might Mandy exhibit?
What physical findings might you find during the physical examination?
How should you manage Mandy’s history of abuse?
SOAP NOTE FORMAT
Subjective
Chief Complaint (CC)
History of Present Illness (HPI) in paragraph form (remember OLDCART: Onset, Location, Duration, Characteristics, Aggravating/Alleviating Factors, Relieving Factors, Treatment)
Past Med. Hx (PMH): Medical or surgical problems, hospitalizations, medications, allergies, immunizations, and preventative health maintenance as applicable
Family Hx: As applicable
Social Hx: Including nutrition, exercise, substance use, sexual hx, occupation, school, etc.
Review of Systems (ROS) as appropriate: Include health maintenance (e.g., eye, dental, pap, vaccines, colonoscopy)
Objective
Vital signs
Physical findings listed by body systems, not paragraph form
Assessment (Diagnosis/ICD10 Code)
Include all diagnoses that apply for this visit
Plan
Dx Plan (lab, x-ray)
Tx Plan: (meds)
Pt. Education, including specific medication teaching points
Referral/Follow-up
Health maintenance (including when screenings, immunizations, etc., are next due)