This chart note summarizes a two-year-old patient's adjustment to their first hospitalization and isolation for respiratory distress and flu-like symptoms. The child cries often and only wants their mother, which is developmentally appropriate. Providing medical play and creating a routine will help familiarize the child with staff and equipment to relieve irritability. Music therapy and visits from the hospital clown are recommended to provide stimulation and social relief.

1. Abigail Caldwell
Chart Note Exercise – SOAP
Subjective – CCLS was approached by the patient’s nurse due to concerns regarding the patient’s
adjustment to hospitalization and isolation.
Objective – This is the patient’s first hospital visit. The patient is a developmentally appropriate
two-year-old admitted for respiratory distress and flu-like symptoms, and is on isolation. The
mother states that the child cries often, and complains of missing their older siblings at home.
The child cries when any medical staff enters the room; they will only let their mother hold them,
and will only be comforted by the mother when crying.
Assessment – The child’s uncomfortable nature around strangers is developmentally appropriate
for a toddler in a threatening environment. Because the patient is on isolation, all medical staff
appear gowned, gloved, and masked up; it is appropriate for the toddler to associate these people
together and be fearful. The child’s favorable manner towards their mother is also
developmentally appropriate, and shows that there is a secure attachment. The patient’s
irritability is appropriate for a toddler in an unknown environment, and on a different routine
than normal. Complaints of missing siblings is appropriate because of the child’s unexpected
isolation.
Plan – Providing opportunities for medical play will help to familiarize the child with the
equipment that the medical staff is using, and engaging with the nurses during medical play will
help the child form a more positive association with staff. Creating a regular schedule for the
two-year-old will help to relieve irritability and exhaustion, especially if allotted a regular rest
time. Music therapy and interactions with the hospital clown will provide developmentally
stimulating activity and social relief for the child by giving them something and someone
different to listen to and play with.