4 months old baby coming in for immunization vaccines 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: Healthy Children.orgLinks to an external site.Links to an external site.https://www.cdc.gov/vaccines/parents/visit/vaccination-during-COVID-19.htmlhttps://brightfutures.aap.org/families/Pages/Well-Child-Visits.aspxhttps://www.healthychildren.org/English/family-life/health-management/Pages/Well-Child-Care-A-Check-Up-for-Success.aspxWell-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?
