Bronchiolitis

SOAP Note
With this assignment, you will demonstrate your ability to document a clinical encounter in the widely accepted SOAP note format. The SOAP note will be based on the given clinical case scenario detailed below.

Clinical Case Scenario
Dx: Bronchiolitis

A 12-month-old presents to your office in January with a 2-day history of runny nose and cough. The child now has wheezing with nasal flaring and retractions, and his oxygen saturation is 89%. There has been no fever, and several of the other children and adults in the family have had a cold over the past several weeks. On examination, you hear scattered wheezes and rales. Allergies: NKDA

To complete this assignment successfully, you will need to read the assignment instructions and accurately address each criterion.

Assignment Instructions
All SOAP note assignments will follow the format below. Your SOAP note must follow the APA format and should include a title page, in-text citations, and a reference page.

SUBJECTIVE
HPI

Document the information given in the case
Include a list of relevant questions you should ask in order to obtain any missing information
Remember OLD CARTS when completing this task.
ROS

Document any symptoms given in the case
Include a list, per body systems, of classic symptoms specific to the given diagnosis.
You may refer to your textbook or other resources to complete this section.
OBJECTIVE
VITAL SIGNS Include a list the following vital signs that correspond to the age of the presented patient document what is given and assign a value to what is missing based on age.
Height & Percentile; Weight & Percentile; Temperature; Blood Pressure; Heart Rate; and Respirations

PE

Document any exam findings given in the case
Include a list, per body systems, of the classic physical examination findings specific to the given diagnosis.
You may refer to your textbook or other resources to complete this section.
ASSESSMENT
Dx

List the given diagnosis with the ICD-10 code. Include a brief description of the pathophysiology.
List TWO differential diagnosis with their ICD-10 codes. Include a brief description of the pathophysiology and a rationale for the chosen differentials.
PLAN
Labs

Document any lab results presented in the case
List any tests youd like to ordered include the reason for the test and what it will show
Plan

Document the information given in the case
Document your treatment and management plan based a National Clinical Guidelines.
You may NOT use your textbook for this; only clinical guidelines
Make sure to include:

Vaccines administered this visit
Medication-amounts and mg/kg for medications
Patient education about the condition including preventive care and anticipatory guidance
Non-medication treatments
Follow-up appointment with detailed plan of f/u
Reflection Include your thoughts about the given case. What did you learn?

The completed SOAP note should be submitted to the appropriate assignment link.

Submission Details:

 

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