SOAP NOTE OF ADOLESCENT SICK PATIENT.

Please write a SOAP NOTE. you’re encouraged to use the resources contained in your weekly syllabus to be sure you have completed all required content.  There is a Focused SOAP CHECKLIST and a Focused SOAP TEMPLATE available for your assistance.  This week’s FOCUSED SOAP will be on a SICK visit on an ADOLESCENT patient.  It must be a sick visit so you can do a detailed Assessment and Management Plan.  If you cannot find a adolescent you may use a school age child but please make a comment with your submission so you are not deducted points.  Please emphasize the Assessment and Plan sections in this paper offering patient evidence and literature based rationale for the clinical decisions made.  

 

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Assignment 2: Episodic Visit: Adolescent Focused Note

 

treatment information, and reflect on health promotion and disease prevention in light of patient factors, such as age, ethnic group, past medical history (PMH), socio-economic status, cultural background, etc. In this week’s Learning Resources, please refer to the Focused Note resources for guidance on writing Focused Notes.

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Note: All Focused Notes must be signed, and each page must be initialed by your preceptor. When you submit your Focused Notes, you should include the complete Focused Note as a Word document and pdf/images of each page that is initialed and signed by your preceptor. You must submit your Focused Notes using SAFE ASSIGN.

Note: Electronic signatures are not accepted. If both files are not received by the due date, faculty will deduct points per the Walden Late Policies.

To prepare:?

  • Review the Focused Note Checklist provided in this week’s Learning Resources and consider how you will develop your Focused Note for this week’s Assignment.
  • Use the Focused SOAP Note Template and the example found in the Learning Resources for this week to complete this Assignment.
  • Select an adolescent patient that you examined during the last 3 weeks. With this patient in mind, address the following in a Focused Note.

Assignment

  • Subjective: What details did the patient or parent provide regarding the personal and medical history? Include any discrepancies between the details provided by the child and details provided by the parent as well as possible reasons for these discrepancies.
  • Objective: What observations did you make during the physical assessment? Include pertinent positive and negative physical exam findings. Describe whether the patient presented with any growth and development or psychosocial issues.
  • Assessment: What were your differential diagnoses? Provide a minimum of three possible diagnoses. List them from highest priority to lowest priority and include their ICD-10 code for the diagnosis. What was your primary diagnosis and why?
  • Plan: What was your plan for diagnostics and primary diagnosis? What was your plan for treatment and management? Include pharmacologic and non-pharmacologic treatments, alternative therapies, and follow-up parameters as well as a rationale for this treatment and management plan.
  • Reflection notes: What was your “aha” moment? What would you do differently in a similar patient evaluation?

RESOURCES:Please use these resources on top of other resources you may use for reference.

Hagan, J. F., Jr., Shaw, J. S., Duncan, P. M. (Eds.). (2017). Bright futures: Guidelines for health supervision of infants, children, and adolescents (4th ed.). American Academy of Pediatrics.

  • “Promoting Healthy Nutrition” (pp. 167–192)(Previously read in Weeks 1 and 2)
  • “Promoting Physical Activity” (pp. 193–203)(Previously read in Weeks 1 and 2)
  • “Promoting Healthy Sexual Development and Sexuality” (pp. 217–227)
  • Promoting Safety and Injury Prevention” (pp. 235–256)(Previously read in Weeks 1 and 2)
  • “Middle Childhood Visits” (pp. 649–730)
  • “Adolescence Visits” (pp. 731–822)

Seidel, H. M., Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2011). Mosby’s guide to physical examination (7th ed.). Mosby.

  • Chapter 26, “Recording Information” (pp. 792–813)

Credit Line: Mosby’s guide to physical examination, 7th Edition by Seidel, H. M., Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. Copyright 2011 by Mosby/Elsevier. Reprinted by permission of Mosby/Elsevier via the Copyright Clearance Center.

 

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