SOAP Note/case presentation of a child or Adolescent

choose a case or disorder and Create a Focused SOAP Note/case presentation of a child or Adolescent. Use the attached template.

 

Subjective:

CC (chief complaint): 

HPI: 

Substance Current Use: 

Medical History: 

· Current Medications: 

· Allergies: 

• Reproductive Hx: 

ROS: 

· GENERAL: 

· HEENT: 

· SKIN: 

· CARDIOVASCULAR: 

· RESPIRATORY: 

· GASTROINTESTINAL: 

· GENITOURINARY: 

· NEUROLOGICAL: 

· MUSCULOSKELETAL: 

· HEMATOLOGIC: 

· LYMPHATICS: 

· ENDOCRINOLOGIC: 

Objective:

Diagnostic results: 

Assessment:

Mental Status Examination: 

Diagnostic Impression: 

PRIMARY DIAGNOSIS(reason you chose this)

3 DIFFERENTIAL DIAGNOSIS(reasons these are ruled out)

Reflections:

Case Formulation and Treatment Plan: 

Five or more recent references