Below is
the template you are to follow when developing your management
plan. Also, always be sure to complete the EMR on the case. Use
this template with each case. It is not a SOAP format as
that is not required. Points will be deducted for not utilizing
the template.
THIS
SECTION IS 30 POINTS!!! Follow the bullet points below. Copy and answer each
bullet point on a word document and cut and paste your responses to the
management section!
Primary
Diagnosis and ICD-10 code
: Also include any
procedural codes.
3-5 Differential Diagnoses-
Why? What made you select each one as a DDX? How
did you rule out? This would be a good area to include references.
Additional laboratory and diagnostic tests:
It may be necessary to establish or evaluate a
condition. Some tests, such as MRI, may require prior authorization from
the patient’s insurance carrier.
Consults:
referrals
to specialists, therapists (physical, occupational), counselors, or other
professionals. If you are sending it to the hospital, what orders would
you write for a direct admit?
Therapeutic modalities:
pharmacological
and nonpharmacological management.
Health Promotion:
Address risk factors as appropriate. Consider
age-appropriate preventive health screening.
Patient education:
Explanations and advice given to patient and
family members.
Disposition/follow-up instructions:
when the patient is to return sooner, and
when to go to another facility such as the emergency department, urgent
care center, specialist, or therapist.
References
(minimum
of 3, timely, that prove this plan follows the current standard of care
Pediatric SOAP Note
Name:
P. L
Date:
03/09/2018
Sex:
Male
Age/DOB/Place of Birth:
16 y.o/03/01/2001/Cuba
SUBJECTIVE
Historian:
Mother and patient
Present Concerns/CC:
“I’ve been having horrible headaches
on and off for the last 2 weeks”
Child Profile:
Patient is a high school student with no
significant past medical history. He is enrolled in a dual program where he
is taking college classes in advance. Described by his mother as an A+
student. He does participate in sports at school being part of the baseball
league. Patient goes to school during the day and spends most of his free
time studying. He eats a balanced diet including meat, vegetables, and salads.
Patient drinks water throughout the day and does not like soda beverages.
Denies drinking energetic drinks. He uses seatbelt at all times while in a
car.
HPI:
Otherwise healthy 16 y/o male seen in the
office for complaints of daily headache for 2 weeks. Pain is described as
dull and pounding and intermittent. Pain is mainly located in the back of the
head but at times radiates to the top and to the sides. Patient can’t say if
there are specific triggers for the pain because he experiences it at any
time. Pain is alleviated by rest and i.
Below isthe template you are to follow when developing your .docx
1. Below is
the template you are to follow when developing your
management
plan. Also, always be sure to complete the EMR on the case.
Use
this template with each case. It is not a SOAP format as
that is not required. Points will be deducted for not utilizing
the template.
THIS
SECTION IS 30 POINTS!!! Follow the bullet points below.
Copy and answer each
bullet point on a word document and cut and paste your
responses to the
management section!
Primary
Diagnosis and ICD-10 code
: Also include any
procedural codes.
3-5 Differential Diagnoses-
Why? What made you select each one as a DDX? How
did you rule out? This would be a good area to include
references.
Additional laboratory and diagnostic tests:
It may be necessary to establish or evaluate a
2. condition. Some tests, such as MRI, may require prior
authorization from
the patient’s insurance carrier.
Consults:
referrals
to specialists, therapists (physical, occupational),
counselors, or other
professionals. If you are sending it to the hospital, what
orders would
you write for a direct admit?
Therapeutic modalities:
pharmacological
and nonpharmacological management.
Health Promotion:
Address risk factors as appropriate. Consider
age-appropriate preventive health screening.
Patient education:
Explanations and advice given to patient and
family members.
Disposition/follow-up instructions:
when the patient is to return sooner, and
when to go to another facility such as the emergency
department, urgent
care center, specialist, or therapist.
References
(minimum
of 3, timely, that prove this plan follows the current standard
of care
4. Age/DOB/Place of Birth:
16 y.o/03/01/2001/Cuba
SUBJECTIVE
Historian:
Mother and patient
Present Concerns/CC:
“I’ve been having horrible headaches
on and off for the last 2 weeks”
Child Profile:
Patient is a high school student with no
significant past medical history. He is enrolled in a dual
program where he
is taking college classes in advance. Described by his mother
as an A+
student. He does participate in sports at school being part of
the baseball
5. league. Patient goes to school during the day and spends most
of his free
time studying. He eats a balanced diet including meat,
vegetables, and salads.
Patient drinks water throughout the day and does not like soda
beverages.
Denies drinking energetic drinks. He uses seatbelt at all times
while in a
car.
HPI:
Otherwise healthy 16 y/o male seen in the
office for complaints of daily headache for 2 weeks. Pain is
described as
dull and pounding and intermittent. Pain is mainly located in
the back of the
head but at times radiates to the top and to the sides. Patient
can’t say if
there are specific triggers for the pain because he experiences
it at any
time. Pain is alleviated by rest and in other instances he has
taken Excedrin
Extra Strength with little relief. Denies photophobia, blurred
vision, or
diplopia. Patient admits to some pressure with the studies as
he is trying to
get a full scholarship for university.
Med
6. Medications
:
Benadryl pen for sleep
Acetaminophen or Advil pen for headache
Excedrin prn
PMHX:
Allergies:
NKA
Medication
Intolerances:
None
7. Chronic Illnesses/Major
traumas:
None
Hospitalizations/Surgeries:
None
Immunizations:
Up to date
Family History
Mother and father
alive.
Mother has history of
GERD and father suffers from HTN. Paternal grandparents are
deceased. Both of
old age. Maternal grandfather and maternal grandmother are
alive, and they
only suffer from GERD and OA.
Social History
Patient is only child and lives with his
parents. He is currently on high school. He is enrolled in a
dual program
where he is taking college classes in advance. He spends most
8. of his time studying.
He has applied to various universities and expects to obtain
full
scholarship. Mother denies guns at home or exposure to second
hand smoking.
Patient does not work because his school requires him to spend
a great amount
of time to it. Both parents are very supportive of patient.
Patient denies
being sexually active and denies having a girlfriend. He has a
group of close
friends.
