xNUR 630 Soap Note 7-year-old Well-Child Check
- $20.00
Subjective
Chief Complaint:
NC is a 7-year-old male seen today in the pediatric office for a well child check. He was last seen a year ago for WCC. NC is doing well with no concerns currently.
HPI:
NC is here today with mother for his 7-year WCC, doing well. No concerns currently. Nutrition: Eating fruits, vegetables and meats, usually well-balanced diet.
Output: stooling and voiding normally. Sleep: All night (8-10 hours), normal for age.
Gross Motor Development: Plays soccer, horseback riding, and enjoys playing at park a couplet time weekly. No deficiencies noted.
Fine Motor: Handwriting is uniform, draws detailed pictures. No deficiencies noted.
Language: Defines words, legible printing, reads two-syllable words, counts to 100, adds and subtracts double digits, correctly spells words at grade level.
School: Doing well in school, is in second grade in public school with good grades. No concerns per teacher or parents.
Social Development: follows rules, helps in chores, plays cooperatively, becoming more aware of other people and their relationship to others, increased sense of empathy, concerns with fairness, has friends.
Development: Discussed body changes, growth, and developmental goals.
Oral Health: Brushing teeth after meals and at bedtime, next visit discussed and recommended for every 6 months.
