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Week 3 child wellness SOAP Note · Write an entire SOAP for the well child visit that took place during immersion. For the child, please use the history you obtained during your encounter. For the chief complaint of all notes, you will write “well visit.” See MSN 572 week 1 content for more information on SOAP note writing. Please use your AAP Bright Future’s guide as the main resource for this assignment. Note that pediatrics will require more information than most SOAP notes, including percentiles for Ht/Wt/BMI, and developmental history, among other differences. · Please plot the height, weight, and BMI for your child on a growth chart (samples can be found on CDC) and include the growth chart with your submission. · Make sure you include a developmental assessment, and for pre-teens and teens, a HEEADSSS assessment. · Preferably, use the format described at immersion by using one of the templates in week one of the course. Make sure to include an assessment (diagnosis) and plan. Do not perform a risk assessment but use actual diagnosis terminology. Be sure to use APA format and include references. Review the rubric before you begin working on the assignment. Criteria Exceeds Expectations Meets Expectations Below Expectations Far Below Standard Identifying Data 5 points Correctly lists all components of the Identifying data including initials, age, DOB, gender, race, ethnicity and whether they came to clinic alone or accompanied and if they are a reliable historian. 4 points Missing one of the elements, or not written in a complete/logical sentence. 2 points Missing 2 or more items. 0 points Not included or written in the wrong area (only in HPI instead of separately). Chief Complaint 5 points Listed the chief complaint in patient's own words with quotation marks “complaint”. CC is brief and not over a sentence long. 4 points Missing one element (not in quotations, not in patients own words, etc). 2 points Incomplete not in the patient's own words. 0 points Not Included History of present illness 15 points HPI written succinctly in paragraph format. If patient has no complaints (such as a wellness visit), the student summarizes the past health history including mo/year of last physical and any pertinent health maintenance or recent lab work. For problem visits, the HPI narrates a story of the patient's problem. If there is a complaint, all elements of HPI are addressed (OLDCARTs or OPQRST) as appropriate for complaint. 13 points Most elements addressed, missing one or two items, but not missing an item that would severely change the treatment of patient. 10 points For any complaint, missing 3 or more of the 7 HPI elements. Or for an annual exam, missing health maintenance history or summary of patient's overall health. Missing an item that would alter the treatment. 7 points <5 variables identified, or not included. May give a zero if not included. Did not provide a synopsis of the patient's problem or health status. Past Medical History 15 points All elements of PMH are described, including medical problem list, surgical history with mo./year of procedure or hospitalization, allergies to environment, food, and drugs, list of meds with doses, and any chemical history (alcohol, drugs, tobacco, caffeine), immunization status. LMP must be included for women of child bearing age. For problem visit, the medical history is pertinent to the problem but meets minimum safety requirements, and always included smoking and allergy information. For wellness exam student expands on diet/nutrition history as well as well as immunizations and health maintenance activities (exercise, sleep, stress). 12 points Mostly complete; missing 1-2 items. May provide too much detail for problem focused visit, or too little detail for wellness exam. 9 points Incomplete, missing 3-4 items or too little detail. 7 points Missing more than half the information. May give a zero if not included. Family History and Social History 10 points For wellness visit, student must include list of relatives including siblings, children, parents, and grandparents and list ages and health problems. For problem visit, provides family history that is pertinent to the problem, such as asking patient about family hx of GI diseases if the pt has a GI compliant. Social history: Student includes occupation, education, housing situation, marital or relationship status, sexual history and practices, spiritual history, and safety practices (guns in home, seat belts, etc., and elaborates even more for children). For problem focused visit, the student includes the social aspects that are pertinent to the problem. 8 points Mostly complete; missing 1-2 items, or giving far too much detail than would be required for problem focused visit (i.e writing about every sexual partner or onset of menses on a visit for simple earache) or documenting too little information for a wellness exam. 6 points Incomplete, missing 3 or more items, or far too much documentation than is required. 4 points Missing more than half the information. May give a zero if not included. Review of Systems 15 points Student includes a complete ROS for an annual/wellness exam and an expanded or problem pertinent ROS for a problem focused visit. The student asks several questions in each category that pertains to the visit. For a wellness exam, the student should review all systems. The student uses the official 14 systems as outlined by page 7 of DHHS/CMS. DHHS/CMS official documentation 12 points Mostly complete; missing 1-2 items. Student may have extra/unnecessary systems for a problem visit or missing 1-2 systems on a wellness exam. 10 points Not comprehensive or not problem focused. Asked only 1 question from each system, or missing more than 2-3 systems, or, for problem focused, contained many extraneous, unnecessary items. Or used an ROS list that is not official. 8 points Incomplete or missing pertinent positives, incomplete or missing pertinent negatives, more than half systems missing. May give a zero if ROS not performed. Objective/Physical Exam Write Up 15 points For all visits, includes vital signs. All peds visits include H/W. For wellness exams and as needed for other visits, includes height/weight/BMI, head circumference (< 2 y.o.). Includes proper documentation of comprehensive physical exam findings with proper medical terminology, as appropriate for the patient's complaint. A full physical is written up for an annual/wellness exam. Exam is age appropriate (includes tanner stages and primitive reflexes as applies to children and infants) 12 points May have missed 1-2 aspects of the physical exam write up, or included extra systems that are not necessary for the patient complaint. Some terminology is inappropriate or not professional (i.e. using laymen's terms or non-medical terms). 9 points Missed vital signs or several aspects of the physical exam write up. Included items that do not align with the complaint. 6 points Missing over half of the physical exam. Assessment and Plan 15 points Student provides a DDX list with at least 3 differentials considered. Student indicates their chosen diagnosis and brief written synopsis of decision making for the diagnosis. Treatment plan includes diagnostic plan, therapeutic plan, patient education (including SEs of meds if ordered) and specific follow up. For well child exams, includes anticipatory guidance/next immunizations. Student specifies labs and radiology and referrals as needed. Student documents any ordered medications as appropriate at provider level; with correct medication form, doses, routes, timing, # ordered, and refills if indicated. 12 points Assessment and plan is mostly complete, maybe missing one element. Did not include DDx list. Missing a detail of the prescription. Missing details of labs or rads or referrals. 10 points Student is missing or several elements of plan or did not clearly indicate the diagnosis. Only mentions the prescription name. 5 points Missing over half the A/P elements, or if not included at all may score the student a zero Format, spelling/grammar, and references 10 points APA format, spelling, and grammar is appropriate. Sentence fluency is present and content is organized and well-written. SOAP note format is organized and easy to follow with clear headings for ID, CC, HPI, History, ROS, VS/PE, Assessment, and Plan and all subsections. There are at least two in-text citations (with matching references) to support the clinical decision making (i.e. support the DX or the treatment plan chosen). Student uses references that are evidence-based, peer-reviewed, and published within the last 5 years and that align with the scope of practice (i.e. provider focused references vs only nursing focused). 8 points APA format is mostly correct with minimal errors. The format has 1-2 errors but they are minor. The student only uses one reference, or does not cite or write the references appropriately. 6 points Several formatting or APA issues. Student does not use citations or references, or they chose references that are inappropriate. 4 points Very poor or no APA format, poor SOAP format, or missing a portion of the SOAP note, or does not use any references. 1 Well Child Soap USU Physical Assessment MSN 572 January 10, 2021 2 Well Child Soap SUBJECTIVE: ID: Manon is a 13-year-old female who came to the clinic for her annual wellness check. She is not an established patient. She is in 8th grade and currently resides with her mother, father, and siblings. Manon states she has not had a wellness check in a while. She has no complaints currently. Pt. M., DOB11/01/07, Age 13-year-old, African American identifies as female, arrived with parents to the clinic but unaccompanied by parents during interview is a reliable source of information. CC: “I am here for my wellness exam” HISTORY OF PRESENT ILLNESS (HPI): 13-year-old female is here for her wellness exam and states she feels well and healthy. She does not recall when her last exam was. She is up to date on her immunizations a flu shot. Denies any medication use apart from allergy medicine prn and an expired Epi pen for emergency use r/t peanut allergy. She last saw her dentist July 2020 for braces removal. She denies any complaints or concerns at this time. Patient presents as a reliable historian. PAST MEDICAL HISTORY: M. is a 13-year-old African American female who presented to clinic for her routine wellness exam. Generally, she feels healthy. She was visiting the dentist monthly until last July as she had her braces removed. She has a difficult time with her retainer often forgetting to remove it prior to eating. Patient verbalizes that she is “pretty healthy.” Patient 3 stated that she broke her R. clavicle at 2.5 years old due to jumping on the bed. No implications post injury. Patient denies surgery. Pt. Verbalizes that she has had one episode of Swimmer’s ear treated with antibiotics with which she cannot remember the name of at this time. Pt. Has been treated for Eczema at the age of 9 which as treated topical creams and has since resolved. PAST MEDICAL PROCEDURES: Patient denies surgeries or hospitalizations. MEDICATIONS: Takes over the counter seasonal allergy medication (Claritin 10mg po once daily prn) and carries an expired Epi pen in the event of an anaphylactic shock due to an allergic reaction. Patient knowledgeable on how to utilize an Epi pen. Educated on obtaining a new Epi pen that is not expired. Patient states taking antibiotics a long time ago for Swimmer’s ear. She takes fish oil for omega-3 daily. Denies any additional vitamins or supplements. ALLERGIES: Patient has severe allergy to peanuts as evidenced by shortness of breath, wheezing, hives, and anaphylactic reaction. Patient also allergic to pollen, dust, and grass which results in sneezing that reoccurs in the Fall and Spring season. No latex allergy noted. LMP (as applies) – Patient stated she had her menses last week. Periods are regular and not painful. Patient started menses at age of 11. Patient states she goes through about two pads per day and period lasts about 5 days. Has one period a month. FAMILY HISTORY- Mother and father have no medical problems. Maternal grandmother has high blood pressure and paternal grandmother has Diabetes Mellitus type I. Patient never met grandfathers. Patient has three sisters ages 15 and 13, 13-year-old who has an allergy to shellfish. No smokers in the family or at home. SOCIAL HISTORY -SEXUAL/REPRODUCTIVE: Patient denies sexual partners. 4 -TOBACCO USE/Vaping: Patient denies smoking or vaping. -ALCOHOL USE: Patient stated she has tried alcohol by accident when father left alcoholic drink on counter and she thought it was orange juice. -DRUG USE: Patient denies drug use. -MARITAL HISTORY: Patient denies marriage. -EDUCATIONAL LEVEL: Patient resides with mother, father, and her siblings. She has a close relationship with her parents. Full time student in 8th grade. Gets A’s and B’s in school. -SOCIAL LEVEL: Patient verbalizes having a small group of friends and denies experiences with bullying. -EXERCISE/DIET: Patient verbalizes she has healthy home-cooked meals and offered examples of foods such as potatoes, rice, chicken, and beef. Patient likes to swim and uses that as her exercise every day at home. Eats fast food about once every two weeks. No weight changes have been noted. -SLEEP/STRESS: Patient is not under stress. She sleeps normally for about 6-9 hours at night. Goes to bed at 11:00PM and wakes up at 8:00AM daily. -SAFETY: Patient wears a helmet, knee pads, and wrist guards during any rollerblading or bicycle riles. Patient maintains safety precautions and wears seatbelt in the backseat of her car. IMMUNIZATIONS- Patient is up to date with all her immunizations appropriate for her age of Tdap, Tetanus diphtheria, pertussis, HPV human papillomavirus all shots, meningococcal, pneumococcal, hepatitis B, hepatitis A, polio, MMR measles, mumps, rubella, chickenpox varicella, and flu shot done on 01/12/20. SPIRITUAL AFFILIATION- Patient is of Christian faith. 5 REVIEW OF SYSTEMS: CONSTITUTIONAL: Denies any concerns and states that she is “pretty healthy.” No changes in weight, no weakness, no malaise. EYES: Denies any vision problems. No aids used for visual aid. Last eye exam performed 06/13/20. EARS, NOSE, MOUTH/THROAT: Denies any headaches, seizures problems. Denies hearing problems or earaches. States that she has a runny nose during the springtime due to allergies. Denies rhinorrhea. Last Dental exam (July 2020). Denies dental problems. Denies any sore throat, tonsillitis, or swallowing problems. CARDIOVASCULAR: Denies heart problems, pain or chest discomfort, or high blood pressure. No chest pain of SOB during exercise. RESPIRATORY: Denies respiratory problems. Experiences shortness of breath and sneezing during allergies. GASTROINTESTINAL: Denies gastrointestinal problems, denies abdominal pain, blood stool, or rectal bleeding. Denies any nausea, vomiting, constipation, or diarrhea. Pt has BM twice every day. GENITOURINARY: N/A MUSCULOSKELETAL: Denies any musculoskeletal problems, joint swelling, or joint stiffness. Denies pain. INTEGUMENTARY/BREAST: Denies any rashes, acne, lesions, moles, or urticaria. NEURO: Patient verbalizes that she experiences mood swings sometimes. Denies headaches, dizziness, numbness, loss in sensations, or weakness. No seizure history noted. 6 PSYCH: Denies depression or anxiety. Patient states she “Gets moody sometimes according to the sister”. ENDOCRINE: Declines heat or cold intolerance or any thyroid problems. Denies excessive thirst. HEMATOLOGIC/LYMPHATIC: Denies anemia, abnormal bruising, or bleeding. ALLERGY/IMMUNOLOGY: Patient has allergy to peanuts, pollen, dust, and grass. OBJECTIVE: PHYSICAL EXAM: VITAL SIGNS: P:80 BP:108/60 RR: 18 T: 97.8 Pain : 0/10 Ht : 58.5 inches tall Wt :46kg (102 lbs) BMI: 18.5 (25th percentile) (Centers for Disease Control and Prevention, 2020) 7 PHYSICAL EXAM: General survey: Patient appears neat, well-groomed, and presentable. HEENT: Skin: Dry, pink, intact. Eyes: extraocular motions full, conjunctiva clear. sclerae non-icteric, pupils' equal round and reactive to light. Ears: Tympanic membrane landmarks well visualized. Nose: No discharge, no obstruction, septum not deviated. Throat: lips pink, no gum or teeth abnormalities, tongue no lesions, no masses Neck: Denies pain. CV: Breasts symmetrical, nontender, no masses or discharges. Pulmonary: Lungs: clear No dullness to percussion. Diaphragm moves well with respiration. No rhonchi, wheezes or rubs. Abdomen/GI: soft, flat, bowel sounds present, no bruits. Nontender to palpation. Liver edge, spleen, kidney not felt. No masses. GU: soft, flat, bowel sounds present, no bruits. M/S: Full range of motions w/o any difficulties. Lymph: No adenopathy Skin: Clean, dry, intact, free of abrasions or contusions Neuro: No history of seizures, stroke, syncope, memory changes, or headache Psych: No history of depression, anxiety, depression, mood changes, or suicidal thoughts 8 DIFFERENTIAL DIAGNOSIS: 1. Food Allergy Z91.018- Anaphylaxis: Patient has a severe allergy to peanuts evidence by patient verbalizing that she experiences SOB and wheezing, which can result in anaphylaxis and hospitalization. Patient currently has an expired EpiPen. 2. Wellness Exam Z00.129: The Academy of Pediatrics states that surveillance be performed at each clinic visit for formal developmental screening. This is to be done at 9, 18, and 30 months (Turner, 2018). 3. Dietary surveillance and counseling Z71.3: “Healthy eating in childhood and adolescence is important for proper growth and development and to prevent various health conditions. The 2015–2020 Dietary Guidelines for Americans external icon recommend that people aged 2 years or older follow a healthy eating pattern” (CDC, 2018). FINAL DX: Wellness Z00.129. (ICD.CODES, 2020). PLAN: -Diagnostic plan: CBC for overall wellness check. -Treatment/Therapeutic Plan: New Rx given for two (2) EpiPen 0.3mg per 0.3 ml Auto-Injectors due to patient having one expired EpiPen on hand. One dose of the EpiPen is to be used IM into the anterolateral aspect of the thigh in the event of the patient ingesting peanuts r/t serve allergy reaction of anaphylaxis. Referrals: None necessary for patient. Education: http://health.gov/dietaryguidelines/2015/guidelines/ 9 1. Educate patient on the importance of having at least two EpiPen’s at hand and the significance of carrying them for an unprecedented event of an anaphylactic reaction as evidence by a sever allergy to peanuts. Would suggest the regular Epi Pen 0.3mg. per 0.3 ml IM prn for allergic reaction. 2. Educate patient on the importance of a healthy diet such as eating a variety of vegetables and fruits, whole grains, fat-free and low-fat dairy products, a good variety of protein- rich foods, and healthy oils derived from fish and vegetables. 3. Educate patient on safety in relation to outdoor activities, particular to having an adult supervision at all times during swimming to prevent a drowning related accident. F/U Plan: 1. F/U in a week about patient getting EpiPen from pharmacy and comprehension level of patient about using the pen properly. 2. Follow up in a month about dietary changes for maintaining a healthy weight and obesity prevention. References 10 American Academy of Pediatrics. (2017). Bright futures: Guidelines for health supervision of infants, children, and adolescents. Centers for Disease Control and Prevention. (2019, May 29). Childhood Nutrition Facts. https://www.cdc.gov/healthyschools/nutrition/facts.htm. Centers for Disease Control and Prevention. (2020, February 2). Easy-to-read immunization schedule by vaccine for ages 7-18 years | CDC. https://www.cdc.gov/vaccines/schedules/easy-to-read/adolescent- easyread.html Turner K. Well-Child Visits for Infants and Young Children. (2018, September 15) Am Fam Physician;98(6):347-353. PMID: 30215922. https://www.cdc.gov/vaccines/schedules/easy-to-read/adolescent-easyread.html https://www.cdc.gov/vaccines/schedules/easy-to-read/adolescent-easyread.html