PATIENT: Make up a pediatric patient Submit a Well-child SOAP note for grading.

PATIENT: Make up a pediatric patient
Submit a Well-child SOAP note for grading. You must use an actual patient from your clinical practicum.
Use the format below for your SOAP note as a reference and add/edit as needed depending on the age of the child/baby
You may refer to the following websites for additional information on the recommended schedule:

Well-child SOAP Note Format
Demographic Data
Age, and gender (must be HIPAA compliant)
Subjective
___-day/week old infant/child accompanied by ___________ and here for a routine well-child/baby check (and vaccines). Any parental concerns/ questions today?
Interval Events/History:
Nutrition:
Elimination:
Sleep:
Medications:
Allergies:
Past Medical
Pregnancy and delivery?
Surgeries, hospitalizations, or serious illnesses to date?
Immunizations?
Development: (describe as applicable to age)
Gross motor:
Fine motor:
Cognitive:
Social/Emotional:
Communication:
Social History: Smoking in the home?
Family life/structure/dynamics? Primary caregivers?
Stressors?
Family History:
Objective (Should be a thorough head to toe assessment)
Vital Signs/growth measurements (weight, length, head circumference, BMI, BP, HR, etc. if applicable)
Physical findings listed by body systems, not paragraph form.
Highlight abnormal findings
Growth Chart Percentages: if applicable
Labs/Studies: if applicable
Assessment
Well-child visit ICD10 code(s)
Plan
Vaccines today:
Anticipatory guidance (discussed or covered in the visit)?
Health Maintenance
Return precautions?
Rubric
Well-Child SOAP Note
Well-Child SOAP Note
CriteriaRatingsPts
This criterion is linked to a Learning OutcomeSubjective
6 to >5.4 ptsAccomplished
All subjective data is included (HPI, interval events, parental concerns (if any), nutrition, elimination, meds, allergies, PMH, developmental, FH, SH). Is complete, concise, and relevant with no extraneous data.
5.4 to >4.8 ptsSatisfactory
Most subjective data is included (HPI, interval events, parental concerns (if any), nutrition, elimination, meds, allergies, PMH, developmental, FH, SH). Some extraneous data is present and/or one minor data point missing.
4.8 to >4.2 ptsNeeds Improvement
Subjective data is missing. There is too much extraneous data and/or 2-3 major data points missing
4.2 to >0 ptsUnsatisfactory
Subjective data is missing or is not organized. Objective or other data is mixed into the subjective data.
6 pts
This criterion is linked to a Learning OutcomeObjective
6 to >5.4 ptsAccomplished
Complete, concise, well organized, and well written with applicable vital signs/growth measurements. Organized by body system in list format. No extraneous data.
5.4 to >4.8 ptsSatisfactory
All relevant exams were done thoroughly but extraneous exams were also done. Somewhat organized in list format. Includes some but not all applicable vital signs or other required information.
4.8 to >4.2 ptsNeeds Improvement
Omitted important relevant exams, vital signs/growth measurements, and/or not in list format.
4.2 to >0 ptsUnsatisfactory
Omitted important relevant exams, vital signs/growth measurements, and/or subjective data are included. Lacking organization.
6 pts
This criterion is linked to a Learning OutcomeAssessment
6 to >5.4 ptsAccomplished
Preventative care coding of well-child/baby visit and ICD10 is correct and includes additionally applicable preventative diagnoses based on age/recommendations.
5.4 to >4.8 ptsSatisfactory
Assessment is correct with ICD10 codes; however, some minor additional applicable preventative diagnoses based on age/recommendations is missing
4.8 to >4.2 ptsNeeds Improvement
Assessment is correct but either does not include ICD10 code or is missing major additional applicable preventative diagnoses based on age/recommendations
4.2 to >0 ptsUnsatisfactory
Assessment is not correct or is not provided. Missing applicable preventative diagnoses based on age/recommendations
6 pts
This criterion is linked to a Learning OutcomePlan
6 to >5.4 ptsAccomplished
Plan is organized, complete and evidence-based according to National Standards of Care. Individualized to the specific patient and all 5 components: (Dx plan, Tx plan, patient education, referral/follow-up, health maintenance).
5.4 to >4.8 ptsSatisfactory
Plan is organized, complete and evidence-based according to National Standards of Care. Addresses each diagnosis and is individualized to the specific patient and includes medication teaching but may be missing 1-2 minor points
4.8 to >4.2 ptsNeeds Improvement
Plan is less organized and not based on evidence according to National Standards of Care. Does not address each diagnosis or may not be individualized to the specific patient. Missing medication teaching or one of the 5 components.
4.2 to >0 ptsUnsatisfactory
No plan is provided or is not organized. Does not address all diagnoses identified and/or does not include all 5 components of plan, including medication teaching.
6 pts
This criterion is linked to a Learning OutcomeProfessional Documentation, Communication, and Engagement
6 to >5.4 ptsAccomplished
Addresses all instructor /preceptor comments and makes all changes and applies feedback as needed. Maintains a positive attitude toward faculty feedback.
5.4 to >4.8 ptsSatisfactory
Responds to and addresses some instructor / preceptor comments or questions and applies most instructor feedback to work. Maintains a positive attitude toward faculty feedback.
4.8 to >4.2 ptsNeeds Improvement
Responds to some instructor / preceptor comments or questions but does not apply that feedback to work. A positive attitude toward faculty feedback needs improvement.
4.2 to >0 ptsUnsatisfactory
Does not respond to any instructor / preceptor comments and questions. Does not address instructor /preceptor comments and does not make the needed changes. Fails to respond and communicate with instructor.
6 pts
Total Points: 30