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
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