use a toddler use with an earache
Purpose:
This assignment is designed to demonstrate your advanced clinical reasoning and decision-making skills as a Nurse Practitioner. You will select a pediatric patient with a chronic or acute condition from your current clinical rotation and develop a comprehensive case analysis, ensuring all patient identifiers remain excluded.
Expectations:
- Infant
- Toddler
- Preschooler
- School-age
- Adolescent
A total of three SOAP notes must be submitted during the term (in Weeks 3, 5, and 7), with each submission covering a different age group.
Each H&P must be submitted to its designated drop box in Canvas with a file name indicating the age group examined. Example: Wallace_HandP_Toddler.docx
A sample pediatric SOAP note template is available in the Resources section of Canvas to guide formatting. Please review the attached rubric for required elements and the grading breakdown.
Critical Thinking & Reflection:
Your write-up should reflect advanced practice thinking beyond basic ordering and prescribing. If, upon completing your analysis, you recognize a missed assessment, teaching opportunity, or disagree with your preceptors plan, include an addendum at the end of your write-up. This section should outline what should have been done differently, offering a valuable opportunity for reflection and professional growth.
Sample SOAP Note Template:
Rubric
Comprehensive SOAP Note Rubric (1) (1)
Comprehensive SOAP Note Rubric (1) (1)
| Criteria |
Ratings |
Pts |
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This criterion is linked to a Learning OutcomeChief Complaint (CC)The chief complaint (CC) is a concise, one-sentence statement describing the primary reason for the patients visit, including symptom duration. It should be documented in the patients or familys own words whenever possible. Example: Patient reported, “I’ve had a cough and sore throat for two days.”
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3 ptsExemplaryClearly stated, includes the reason for the visit, accurately reflects the patients primary concern, is appropriate for the type of write-up, and is documented in the patients or familys own words.2 ptsProficientIncludes the reason for the visit and is appropriate for the type of write-up but is not documented in the patients or familys own words.
1 ptsNeeds ImprovementThe chief complaint (CC) lacks clarity, is not appropriate for the type of write-up, and is not documented in the patients or familys own words.0 ptsNot EvidentNot included. |
3 pts
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This criterion is linked to a Learning OutcomeHistory of Present Illness (HPI)The History of Present Illness (HPI) utilizes OLD CARTS or PQRST to ensure a thorough assessment of the patients symptoms.
This includes:
Onset: When the symptoms began.
Location: Where the symptom is felt.
Duration: How long it has persisted.
Characteristics: Description of the sensation (sharp, dull, burning, etc.).
Aggravating/Alleviating Factors: What makes it worse or better.
Related Symptoms: Any associated issues.
Treatments: Interventions that have been tried.
Significance: Impact on daily life.
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7 ptsExemplaryComprehensive and focused, capturing all relevant details of the current illness and symptoms while omitting unnecessary information. Uses OLD CARTS or PQRST to systematically evaluate all key components, ensuring a thorough and efficient assessment of the patients condition.5 ptsProficientIncludes pertinent information but misses one to two key components or contains some irrelevant details. No objective data included.
3 ptsNeeds ImprovementSuperficial assessment, missing three or more key components, includes irrelevant details, or incorporates objective data inappropriately.0 ptsNot EvidentNot included. |
7 pts
|
|
This criterion is linked to a Learning OutcomeMedications1. Current Medications: A complete, concise, and well-organized list of all current medications, including prescription, over-the-counter (OTC), and PRN medications. Each medication entry must include:
Drug name, dose, frequency, route, and time of last dose.
Indication (patient-stated reason for taking each medication).
2. Allergies: Medication allergies must be clearly documented, including the specific type of reaction. If no known drug allergies (NKDA), this must be stated.
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3 ptsExemplaryA complete, concise, and well-organized summary of all current medications, including drug name, dose, frequency, route, time of last dose, and indication for each medication. Medication allergies are clearly documented, including the type of reaction. AND Food, drug, environmental allergies are clearly documented, including the type of reaction.2 ptsProficientMedication list is included but omits one to two key details. OR Allergies to food and medications are documented, but the type of reaction is missing or NKDA is not recorded.
1 ptsNeeds ImprovementMedication list is present but omits three or more key details. OR Allergies are not documented.0 ptsNot EvidentNot included. |
3 pts
|
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This criterion is linked to a Learning OutcomeHistoryA comprehensive history should include:
1. Past medical history (Includes chronic illnesses, hospitalizations, and significant past conditions.)
2. Past Surgical history
3. Family history (Covers 2 generations)
4. Immunization history
5. Allergy history (Documents medication, food, and environmental allergies, including reactions)
6. Personal and Social history
Diet and Exercise
Spirituality/School/Work
Birth History: Reviews prenatal, perinatal, and neonatal details (if applicable).
Exposure History: Screens for TB exposure and lead exposure.
Activities of Daily Living (ADLs) and Habits
Sexual History
Chemical History: Documents smoking, drug use, alcohol consumption, and other substance exposures.
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6 ptsExemplaryProvides a comprehensive past medical and surgical history, covering chronic illnesses, hospitalizations, and procedures. Family history extends two generations, identifying hereditary conditions. Immunization and allergy history are reviewed for completeness and accuracy. Social history includes diet, exercise, spirituality, school/work, birth details, TB and lead exposure, ADLs, habits, sexual activity, and substance use.4 ptsProficientHistory is provided but superficial or omits two to three key details from medical, family, immunization, or social history.
2 ptsNeeds ImprovementHistory is superficial and omits three or more key details from medical, family, immunization, or social history.0 ptsNot EvidentNot included. |
6 pts
|
|
This criterion is linked to a Learning OutcomeGrowth and DevelopmentA comprehensive growth and development assessment should include:
Physical Growth: Assesses the patients growth, including a plotted height and weight chart (marked for the patient’s measurements and attached in the appendix).
Motor Development: Assesses motor skills and coordination.
Cognitive Development: Examines cognitive abilities and problem-solving skills.
Verbal Development: Assesses language and communication skills.
Social Development: Observes social interactions and behavioral patterns.
Developmental Stages and Stage Identification: Summarizes the patients developmental stages according to Erikson and Piagets theories. Identifies the patients current stage with a clear rationale and assesses whether their development aligns with their chronological age.
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3 ptsExemplaryComplete, concise, and well-organized summary of the growth and development assessment. All key components are included, and the growth chart is attached in the appendix.2 ptsProficientWell-organized and accurate summary of the growth and development assessment. No major omissions noted, but minor details may be lacking.
1 ptsNeeds ImprovementPoorly organized and/or incomplete summary of growth and development assessment. One key omission is noted.0 ptsNot EvidentNot included |
3 pts
|
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This criterion is linked to a Learning OutcomeReview of Systems (ROS)A thorough Review of Systems (ROS) should include a clear narrative assessment of the following systems:
General
Eyes
Ears/Nose/Throat
Endocrine
Cardiovascular
Respiratory
Gastrointestinal
Genitourinary
Hematology
Lymph
Integumentary
Neck
Neurological
Musculoskeletal
Psychological
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5 ptsExemplaryComplete ROS addressing each system with a clear narrative. Avoids vague terms like “within normal limits.” No objective data included.3 ptsProficientROS is mostly complete but missing two to three systems.
2 ptsNeeds ImprovementROS is incomplete, missing four or more systems.0 ptsNot EvidentNo ROS attempted. |
5 pts
|
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This criterion is linked to a Learning OutcomeObjective dataA thorough Objective Data section should include:
1. Vital Signs and Measurements
Blood Pressure (BP)
Temperature (Temp)
Pulse
Respiratory Rate (RR)
Height (with percentile %)
Weight (with percentile %)
Body Mass Index (BMI) (with percentile % and category: normal, overweight, obese, etc.)
2. Physical Examination
General
Eyes/Ears/Nose/Throat
Endocrine
Cardiovascular
Respiratory
Gastrointestinal
Genitourinary
Hematology/Lymph
Integumentary
Neck
Neurological
Musculoskeletal (include assessment of spine)
Psychological
3. Labs and Diagnostics
Any available lab results or pending diagnostics should be documented.
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5 ptsExemplaryIncludes all vital signs and measurements, with BMI properly categorized. Physical exam is complete, covering all required systems. Any available labs or diagnostics are documented appropriately.3 ptsProficientMissing BMI categorization or two to three physical exam components. Labs or diagnostics are included but incompletely documented.
2.14 ptsNeeds ImprovementMissing vital signs, an incomplete physical exam with four or more missing components, and fails to document labs or diagnostics.0 ptsNot EvidentNot included. |
5 pts
|
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This criterion is linked to a Learning OutcomeAssessmentThe Assessment section includes a well-organized and prioritized list of differential diagnoses based on the chief complaint (CC), review of systems (ROS), and physical exam (PE). Each differential diagnosis should be supported with subjective and objective data, and rationale.
The most likely (presumptive) diagnosis should be clearly identified, with a justification that includes pathophysiology.
The rationale should explain the inclusion and exclusion of differential diagnoses, demonstrating clinical reasoning. ICD-10 codes must be assigned accurately to all diagnoses
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7 ptsExemplaryIncludes more than three differential diagnoses based on the CC, ROS, and PE, with strong subjective and objective data, rationale, and diagnostic testing. The list is well-organized and prioritized using clinical reasoning. Identifies the most likely (presumptive) diagnosis with a clear justification, including pathophysiology. Explains the inclusion and exclusion of differentials. ICD-10 codes are accurate.5 ptsProficientIncludes at least three differential diagnoses with general support but lacks depth in rationale or diagnostic testing. The list is organized and prioritized, though reasoning may be underdeveloped. The presumptive diagnosis has a reasonable but somewhat limited justification, including pathophysiology. ICD-10 codes included but may have minor errors.
3 ptsNeeds ImprovementIncludes fewer than three differential diagnoses or unrelated diagnoses. Support is minimal or unclear, lacking subjective/objective data or diagnostic testing. The list is poorly organized with weak justification for the presumptive diagnosis, and pathophysiology is missing. ICD-10 codes may be missing or incorrect.0 ptsNot EvidentNo effort. |
7 pts
|
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This criterion is linked to a Learning OutcomePlanThe Plan outlines a structured approach to patient care, including:
Labs/Tests: Orders appropriate diagnostic tests and notes pending results.
Medications: Prescribes or refills medications with correct dosing and instructions.
Interventions: Incorporates both pharmacological and non-pharmacological treatments.
Referrals: Provides necessary referrals when applicable.
Patient Education: Includes tailored health instructions to support management.
Follow-Up: Specifies the timeline and next steps for continued care.
Rationales: Citations for interventions to ensure evidence-based practice.
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7 ptsExemplaryA thorough plan addressing all components, including appropriate diagnostic tests, medications with proper dosing, and a combination of pharmacological and non-pharmacological interventions. Includes necessary referrals, detailed patient education, and a clear follow-up plan. Citations for interventions ensure evidence-based care.5 ptsProficientMostly complete but missing one to two components.
3 ptsNeeds ImprovementPlan is superficial, missing three or more components, or lacks evidence-based support. Citations are missing.0 ptsNot EvidentPlan is not included or inappropriate for the patient visit. |
7 pts
|
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This criterion is linked to a Learning OutcomeFormatting/APA
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4 ptsExemplaryNo errors in grammar or spelling. No APA errors. Write-up is in proper format.3 ptsProficient1-2 spelling/grammar errors or 1-2 APA errors.
2 ptsNeeds Improvement3-4 spelling/grammar errors OR 3-4 APA errors OR improper format.0 ptsNot Evident5+ spelling/grammar errors OR 5+ APA errors. |
4 pts
|
Total Points: 50
Clinical Documentation Template
Student Name and clinical course: (If no title page): ______________________
ID:
Clients Initials*:_______Age_____ Race__________Gender____________Date of Birth___________
Insurance _______________Marital Status_____________
Subjective:
CC: a brief statement of the main issue and duration, as reported by the patient or caregiver. Example: Patient reported “I’ve had a cough and sore throat for two days.
HPI: utilizes OLD CARTS or PQRST to ensure a thorough assessment of the patients symptoms.
Medications: include name, dose, frequency, and route. Include PRN medications and how often they are taken.
Allergies: Food, drug, and environmental: List medications and food allergies, specify type of reaction
Past Medical History:
- Medical problem list: details on past and present illnesses, be careful not to blindly copy from prior clinical notes
- Past Surgical History: Past surgeries with dates
- Preventative care: (if applicable to the case – Paps, mammography, colonoscopy, dates of last visits, etc.)
- Hospitalizations: past hospitalizations with reason for admit, duration of stay, and rough dates
- GYN History: LMP, pregnancy status, menopause
Family History: go back 2 generation indicate if alive, deceased, or unknown. details on family members, their age, and illnesses/conditions.
Social History
- Sexual history and contraception/protection (as applies to the case)
- Chemical history (tobacco/alcohol/drugs) (ask every pt about tobacco use)
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)
TB exposure:
Lead exposure:
Immunization History:
Growth and Development: Physical Growth (Include p, Motor, Cognitive, Verbal, Social
ROS (write out by system): Comprehensive (>10) ROS systems for wellness exams or complex cases only. Do not include diagnoses – those belong in PMH. Include only subjective data which patient reports or denies. Do not include any objective data which should go under physical examination. The below categories are per CMS guidelines.
Constitutional:
Eyes:
Ears/Nose/Mouth/Throat:
Cardiovascular:
Pulmonary:
Gastrointestinal:
Genitourinary:
Musculoskeletal:
Integumentary & breast:
Neurological:
Psychiatric:
Endocrine:
Hematologic/Lymphatic:
Allergic/Immunologic:
Objective
Vital Signs:HRBPTempRRSpO2Pain
HeightWeight BMI(be sure to include percentiles for peds)
Labs, radiology or other pertinent studies: be sure to include the date of labs – might be POC tests from today
Physical Exam (write out by system):
General:
Skin:
HEENT (Head, Eyes, Ears, Nose, Throat):
Neck:
Cardiovascular (Heart):
Respiratory (Lungs):
Abdomen:
Back:
Rectal:
Extremities:
Musculoskeletal:
Neurologic:
Psychiatric:
Pelvic:
Breast:
Genitourinary (G/U):
Assessment
(you will often have more than one diagnosis/problem, but do the differential on the main problem, Support diagnoses with evidence-based references.)
Differentials (with a brief rationale for each):
1.
2.
3.
Diagnosis (may have more than one, include ICD-10 if rubric or as your instructor specifies)
Plan (4-pronged plan for each problem on the problem list, Support plans with national guidelines or evidence-based references. Plan include current diagnosis and diagnoses on PMH)
Diagnostics:
Treatment:
Education
Follow Up:
Reference
List plan under each Diagnosis.
Example
1: Hypertension (I10) (Whelton et al., 2017; World Health Organization, 2021)
A: Lisinopril/HCT 20/12.5 Daily #90, refills 3
B: BMP in 6 months
C: Recheck BP in 2 Weeks
D: Low Sodium Diet and lifestyle modifications discussed
2: Morbid Obesity BMI XX.X (E66.01) (Garvey et al., 2016)
A: Goal of 5% weight reduction in 3 months
B: Increase exercise by walking 30 minutes each day
C: Portion Size Education
3: T2 Diabetes with diabetic neuropathy (E11.21) (Qaseem et al., 2017)
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
Addendum (Add additional note at the end of the write-up labeled Addendum if anything was missing from the encounter that should have been done or ordered.):
References (Reference title centered)
Garvey, W. T., Mechanick, J. I., Brett, E. M., et al. (2016). American Association of Clinical Endocrinologists and
American College of Endocrinology comprehensive clinical practice guidelines for medical care of patients with obesity. Endocrine Practice, 22(Suppl. 3), 1203.
Qaseem, A., Barry, M. J., Humphrey, L. L., et al. (2017). Oral pharmacologic treatment of type 2 diabetes mellitus: A
clinical practice guideline update from the American College of Physicians. Annals of Internal Medicine, 166(4), 279290.
Whelton, P. K., Carey, R. M., Aronow, W. S., Casey, D. E., Collins, K. J., Dennison-Himmelfarb, C., et al. (2018). 2017
ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults: A report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Journal of the American College of Cardiology, 71(19), e127e248.
World Health Organization. (2021). Guideline for the pharmacological treatment of hypertension in adults. World Health
Organization.