Case: Patient 9 yr old F African American
Normal assessment
Education:
Non-educational electronics use to less than 2 hours per day
Sleep at least 8 hrs at night
Exercise at least 30 minutes 3 times a week
Dentist visit 2 times a year and brush teeth 2 times per day
Smoke detectors at home
Look both sides when crossing the street
Follow-up in 1 year or PRN
Z00.129 | Encntr for routine child health exam w/o abnormal findings
Subjective, Objective, Assessment, Plan (SOAP) Notes
| Student name: | Course: |
| Patient name (initials only): | Date: Time: |
| Ethnicity: | Age: Sex: |
| SUBJECTIVE | |
| CC: | |
| HPI: | |
| Medications: | |
| Past medical history: | |
| Allergies: | |
| Birth hx: (use only on well child visits): | |
| Immunizations: | |
| Hospitalizations: | |
| Past surgical history: | |
| Social history: | |
| Developmental Assessment: (include on well child visit only but may be necessary for problem focused notes)
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| FAMILY HISTORY | |
| Mother: | |
| MGM: | |
| MGF: | |
| Father: | |
| PGM: | |
| PGF: | |
| REVIEW OF SYSTEMS | |
| General: | Cardiovascular: |
| Skin: | Respiratory: |
| Eyes: | Gastrointestinal: |
| Ears: | Genitourinary/Gynecological: |
| Nose/Mouth/Throat: | Musculoskeletal: |
| Breast: Heme/Lymph/Endo: | Neurological: |
| Psychiatry: | |
| OBJECTIVE (Document PERTINENT systems only, Minimum 3 for problem focused, all systems for well child exam) | |
| Weight: Height: BMI: BP: Temp: Pulse: Resp:
(Insert plotted growth chart below on all well child soap notes) |
|
| General appearance: | |
| Skin: | |
| HEENT: | |
| Cardiovascular: | |
| Respiratory: | |
| Gastrointestinal: | |
| Genitourinary: | |
| Musculoskeletal: | |
| Neurological: | |
| Psychiatric: | |
| Labs performed in office the day of visit: | |
| Diagnosis (must complete this section and explain how all differential diagnoses were ruled in or ruled out) | |
| Differential diagnoses:
1. Diagnosis, (ICD 10 code and reference):
2. Diagnosis, (ICD 10 code and reference):
3. Diagnosis (ICD 10 code and reference): |
Diagnosis (ICD 10 code and reference): |
| Plan/therapeutics/diagnostics; | |
| Education provided: | |
| CPT Code:
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| Anticipatory guidance (well child visit only) | |
Struggling with where to start this assignment? Follow this guide to tackle your assignment easily!
Step-by-Step Guide to Writing SOAP Notes for a Pediatric Well-Child Exam
This guide will help you organize and complete a detailed SOAP note for a 9-year-old African American female patient’s routine well-child visit, using the provided case and clinical documentation format.
Step 1: Fill Out Patient Demographics and Visit Information
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Use initials only for the patient’s name
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Include date and time of visit
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Record ethnicity, age, and sex clearly at the top
Step 2: Write the SUBJECTIVE Section
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Chief Complaint (CC): Usually “Well child check” or “Routine health exam” for this visit
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History of Present Illness (HPI): Since this is a routine exam with no complaints, note “No current complaints” or “Routine health maintenance visit”
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Medications: Document any current meds if applicable or write “None”
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Past Medical History: Note if the child is healthy with no chronic illnesses
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Allergies: Document any known allergies or “No known allergies”
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Birth History: Important for well-child visits; note any complications or “Unremarkable” if none
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Immunizations: List current immunization status or “Up to date”
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Hospitalizations and Past Surgical History: Record if any or state “None”
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Social History: Include living situation, school attendance, exposure to smoke, pets, safety measures, screen time, exercise habits, diet, etc. (Use the education notes provided: e.g., “Electronic use <2 hrs/day, exercises 30 min 3x/week”)
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Developmental Assessment: Comment on age-appropriate developmental milestones for 9 years
Step 3: Complete Family History
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Document health status or chronic diseases in mother, father, maternal and paternal grandparents (MGM, MGF, PGM, PGF) if known
Step 4: Conduct and Document Review of Systems (ROS)
For a well-child exam, cover all systems briefly and document “No complaints” or “WNL (within normal limits)” for each system unless there is a concern.
Step 5: Record the OBJECTIVE Findings
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Vital Signs: Weight, Height, BMI percentile (plot on growth chart), Blood Pressure, Temperature, Pulse, Respirations
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General Appearance: Well-developed, well-nourished, alert
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Skin: Normal, no rashes or lesions
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HEENT: Head atraumatic, eyes clear, ears normal, oral mucosa healthy
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Cardiovascular: Regular rate and rhythm, no murmurs
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Respiratory: Clear breath sounds, no wheezing
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Gastrointestinal: Abdomen soft, non-tender
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Genitourinary: Normal external exam if applicable
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Musculoskeletal: Full range of motion, no deformities
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Neurological: Alert, appropriate reflexes
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Psychiatric: Appropriate affect and behavior for age
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Labs: Document if any tests were done (usually none for routine visits)
Step 6: List Diagnosis and Differential Diagnoses
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Primary diagnosis:
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Z00.129 — Encounter for routine child health exam without abnormal findings
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Explain ruling out of other concerns based on history and exam (e.g., no signs of asthma, infection, growth abnormalities)
Step 7: Write the PLAN
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Therapeutics/Diagnostics: None required for normal well-child exam
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Education Provided:
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Limit electronics to less than 2 hours/day
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Sleep at least 8 hours per night
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Exercise 30 minutes, 3 times per week
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Maintain dental hygiene with twice daily brushing and biannual dentist visits
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Home safety measures like smoke detectors
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Pedestrian safety (look both ways before crossing)
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Follow-up: Routine well-child visit in 1 year or as needed (PRN)
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CPT Code: Use appropriate code for routine pediatric well visit (e.g., 99393 for ages 5–11 years)
Step 8: Include Anticipatory Guidance
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Counsel patient and family on healthy lifestyle habits
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Discuss growth and development expectations
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Reinforce safety and injury prevention
Step 9: Review, Format, and Submit
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Use clear, professional language
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Follow APA or institutional formatting as required
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Submit on time via Canvas or assigned platform
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