Nr 509 Pediatric Soap Note Advanced Physical Assessment

SOAP Note TemplateInitials: D. R. Age: 8 years old Gender: MHeight Weight BP HR RR Temp SPO2 Pain Allergies 127 cm 40.8 kg 120/76 100 28 37.2 C 96 Choose an item. Medication: NKAFood: NKAEnvironment: NKA History of Present Illness (HPI)Chief Complaint (CC) Been feeling sick. I have been coughing a lot. Feeling kind of tired. CC is a BRIEF statement identifying why the patient is here - in the patients own words - for instance "headache", NOT "bad headache for 3 days. Sometimes a patient has more than one complaint. For example: If the patient presents with cough and sore throat, identify which is the CC and which may be an associated symptomO nset Started coughing on the bus on the way to schoolL ocation Throat and right earD uration Coughing - 5 days, constant; ear - one day C haracteristics Gurgly and watery A ggravating Factors Stays the same no matter what I do. It seems to get worse at night.R elieving Factors Cough medicine T reatment Cough medicine Current Medications: Include dosage, frequency, length of time used and reason for use; also include OTC or homeopathic products.Medication (Rx, OTC, or Homeopathic) Dosage Frequency Length of TimeUsed Reason