Wellness visit soap note

Developmental Milestones EXAMPLE-

Social: EX: V.L. is very friendly and get along well with other kids of his age.

Language: EX: V.L. can says words like mama, papa and waves bye-bye.

Speech: EX: His speech is clear and appropriate for his age.

Cognitive: EX: He can recognize some colors and shapes. He picks up toys and puts them in the box.

Motor: EX: he interacts and plays with other children; imaginative play; draws recognizable pictures; Walking and climbing, skips on 1 foot, climbs stairs alternating feet without support (Bright Futures, 2017)

Self help: EX: Potty trained at 2 ½ years old, regular bowel movements; brushes his teeth; dresses and undresses without help

Developmental Milestones FOR INFANTS ONLY: EXAMPLE-

Social: EX: V.L. is very friendly and get along well with other kids of his age.

Language: EX: V.L. can says words like mama, papa and waves bye-bye.

Speech: EX: His speech is clear and appropriate for his age.

Cognitive: EX: He can recognize some colors and shapes. He picks up toys and puts them in the box.

Gross motor: EX: V.L. can walk few steps without support. He picks up toys and puts them in the box.

Fine motor: EX: Can hold pencil with his fist and scribbles in the paper (Misirliyan et al., 2023).

Family History

Mother:

Father:

Siblings:

Maternal grandmother:

Maternal grandfather:

Paternal grandmother:

Paternal grandfather:

Social History

Living condition: V.L. lives in a single-family home with his parents and brother. He stays home with his mother. He doesn’t go to any day care or play school.

Financial resources: Fathers works as engineer, mother works part-time as a teacher; They have health insurance

School performance: has peer interactions

Safety: When riding in a motor vehicle, V.L. is always buckled up and is seated in a car seat rear facing. There is no pool or gun at home. Medication cabinets are always locked. Has a pet cat.

Diet: drinks Enfamil baby formula and water. He also eats rice cereal and pureed fruits and vegetables.

Exercise: He is very active. Likes to plays with his brother at home. He plays with kids of his age when he goes to the playground.

Sleep: sleeps through the night. He sleeps 10-12 hours at night and 2-3 hours in the afternoon when he naps.

Behavior: Normal age-appropriate behavior.

Exposure: No exposure to second hand smoking, alcohol or any other drug use in the family.

Screen time: 45 minutes daily

Spiritual Affiliation: Christian. Goes to church on Sundays.

Other: -Other social history
as applicable to each case (diet/exercise, spirituality, school/work, living arrangements, developmental history, birth history, breastfeeding, ADLs, advanced directives, etc. Exercise your critical thinking here – what is pertinent and necessary for safe and holistic care)

Birth History: (ONLY FOR INFANT) EXAMPLE-

Gestation: Ex: Full term at 39 weeks

Delivery Method: Ex: Spontaneous vaginal delivery

Birth Complications: Ex: None

Birth weight: Ex: 7 pounds, 7 ounces

Birth Length: Ex: 21.5 inches

Breastfed: Ex: Yes. Until 8 months

Review of Systems (ROS): (write out by system):
Comprehensive (
>10) ROS systems for wellness exams or complex cases only. Do not include all 14 systems for every SOAP unless needed – review and document the

pertinent systems.
Do not include diagnoses – those belong in PMH. The below categories are per CMS guidelines

Constitutional: obese child.

Eyes:

Ears/Nose/Mouth/Throat:

Cardiovascular:

Pulmonary:

Gastrointestinal:

Genitourinary:

Musculoskeletal:

Integumentary & breast:

Neurological:

Psychiatric:

Endocrine:

Hematologic/Lymphatic:

Allergic/Immunologic:

OBJECTIVE

Vital Signs: (be sure to include percentiles for peds)

Temperature:

HR:

BP

RR:

SpO2:

Pain:

Height: 31.5 inches (98th percentile- See the plotted growth chart below)

Weight: 10.5 kg (75th Percentile- See the plotted growth chart below)

Head Circumference: 18.5 inches (75th Percentile-See the plotted growth chart below)

BMI: 16.14- Normal

Physical Exam (write out by system):

General Survey:

Head:

Eyes:

Ears:

Nose:

Throat

Neck:

Cardiovascular:

Respiratory:

Gastrointestinal:

Genitourinary: EX: No diaper rash was observed, and the female genitalia were normal. Tanner first stage.

Musculoskeletal: EX: Able to move all extremities freely. Has begun to walk normally for his age. Pink, warm, dry, and flawless skin. Ecchymosis, rashes, moles, or lesions were not present.

Neuro: EX: conscious and aware. Smiles and acknowledges his name. Meeting developmental goals.

Psych: EX: Pleasant personality, bit timid with healthcare provider, but age appropriate. Age-appropriate interaction with mother.

ASSESSMENT

(you will often have more than one diagnosis/problem, but do the differential on the main problem)

Differential Diagnosis (with a brief rationale, and references for each one:

1. Encounter for routine child health examination without abnormal findings

2. Allergy to seafood

3. Encounter for immunization

Final Diagnosis Acne vulgaris

PLAN
(4 pronged-plan for each problem on the problem list) use clinical guidelines to develop treatment plans for your patients

Diagnostics:

Treatment: (please use Guidelines reference) use clinical guidelines to develop treatment plans for your patients

Education/
Anticipatory Guidance:

EX:

1. Health/Developmental – Encourage parents to keep developing nap and bedtime routines creating a tooth-brushing regimen, and scheduling dental appointments. Remind parents to employ constructive punishment and to avoid watching TV or other media.

2. Safety – Inform parents on how to use a car seat correctly, how to remove or lock up poisonous items to prevent accidental poisonings, where to find the poison control number, how to stay safe around water, how to use sunscreen and other protective equipment, how to avoid choking hazards with pets, how to install gates near stairs, and other ways to make the home a safer place.

3. Diet – Promote the benefits of following a balanced diet, which should include three meals and two to three snacks per day, as well as the promotion of self-feeding and the avoidance of tiny, hard foods (Philips et al., 2019).

EX: Education to the parents should be the safety and milestones he will continue to have. Some new motor milestones may include balancing on foot, hops (Bright Futures). Some language milestones may include counting up to 10, naming 4 or more colors (Bright Futures). He may also draw a person with at least 6 body parts and copy squares and triangles (Bright Futures).

Follow Up: EX: Follow up with immunization, hearing, oral health, and vision. Order for bloodwork. Maintain appropriate diet, and exercise for his age group. Such as implementing vegetables and fruits into diet. As for exercise if he plays a sport it should be at most four hours per week/

EX: Administer scheduled vaccinations: Hepatitis A, MMR, Varicella according to CDC vaccine schedule for infants.

Referral to dentist- If not established with one already. This is for dental checkups and routine clean ups.

Return in three months for a 15-month well-child exam and vaccines.

Follow up as necessary if sick or any other issues.

Prescriptions two refills on epi pen autoinjector; Dose 0.15mg (0.3 ml)

Side effects: weakness, shaking, fear, dizziness headache, anxiety, paleness, throbbing, and tenseness (How EpiPen works)

List plan under each Diagnosis.

Example

1: Morbid Obesity BMI XX.X (E66.01)

A: Goal of 5% weight reduction in 3 months

B: Increase exercise by walking 30 minutes each day

C: Portion Size Education

2: T2 Diabetes with diabetic neuropathy (E11.21)

A: Repeat A1C in 3 months

B. Increase Metformin to 1000mg BID #180, refills: 3

C: Annual referral to diabetic educator, ophthalmology, and podiatry (placed X/X)

D: Daily blood glucose check in the am and when sick

E. Return to clinic in 3-4 months to reassess

EXAMPLE CHART: for (2-20 years) (MALE)

EXAMPLE: for BABIES/INFANTS (birth-24 months)

References

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