use this information to create a full soap note according to the requirements:
S (Subjective): “CC: Rash
HPI: O.H. is a 6-month-old male presenting with a 1-week history of a dry, itchy rash. Mother reports rash began under his neck and has spread to the arms and legs. Rash appears worse at night, and the infant has been more irritable with increased rubbing of affected areas. Mother has tried over-the-counter baby lotion with minimal improvement. Patient is currently using half formula and half donor milk. No new foods have been introduced recently. No new soaps or detergents. No fever, vomiting, or diarrhea. Feeding well. Immunizations are up to date.
PMH: None
ROS:
- General: Mother denies fever, chills, or fatigue
- Skin: Positive for dry, erythematous rash under his neck that spread to his arms and legs; reports itching and rubbing; no drainage
- Respiratory: Denies cough or wheezing
- Cardiovascular: Denies cyanosis or feeding intolerance
- Gastrointestinal: Denies vomiting, diarrhea, or constipation
- Psychiatric/Behavioral: Increased irritability, especially at night
O (Objective):
- General: Well-developed 6-month-old female, alert, mildly irritable but consolable
- Skin: Dry, erythematous, patchy rash on bilateral cheeks, extensor surfaces of arms and legs; mild scaling noted; no signs of infection (no crusting, drainage, or pustules)
- Thorax and Lungs: Symmetrical expansion; respirations nonlabored; lungs clear bilaterally
- Cardiovascular: Regular rate and rhythm; S1, S2 present; no murmurs
- Abdomen: Soft, non-tender, bowel sounds present
- Neurological: Alert, active, age-appropriate
A (Assessment): Atopic Dermatitis (Eczema)
P (Plan):
- Medications:
Hydrocortisone 1% cream, apply a thin layer to affected areas BID for 57 days, then stop. - Patient Education:
Educated the caregiver on the chronic nature of eczema and the importance of skin hydration
Use fragrance-free emollients (e.g., petroleum jelly) multiple times daily
Apply moisturizer immediately after bathing (soak and seal)
Use lukewarm baths and mild, unscented soaps
Avoid triggers such as scented detergents, harsh fabrics, and overheating
Keep the infants nails short to prevent skin damage - Follow-up:
Return to clinic if no improvement in 12 weeks, worsening rash, or signs of infection (yellow crusting, drainage, fever) - Referrals:
None at this time - ******* this is the template for the assigment with the required components if the assignment*******
- Clinical Documentation TemplateStudent 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 acough 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 reactionPast 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
- Hospitalizations: past hospitalizations with reason for admit, duration of stay, and rough dates
- Sexual history and contraception/protection (as applies to the case)
- Chemical history (tobacco/alcohol/drugs) (ask every pt about tobacco use)
Preventative care: (if applicable to the case – Paps, mammography, colonoscopy, dates of last visits, etc.)
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
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: HR BP Temp RR SpO2 Pain
Height Weight 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)
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