Student name:

Course:

Patient name (initials only):

Date: Time:

Ethnicity:

Age: Sex:

SUBJECTIVE

CC:

HPI:

Medications:

Past medical history:

Allergies:

Birth hx: (use only on well child visits):

Immunizations:

Hospitalizations:

Past surgical history:

Social history:

Developmental Assessment: (include on well child visit only but may be necessary for problem focused notes)

FAMILY HISTORY

Mother:

MGM:

MGF:

Father:

PGM:

PGF:

REVIEW OF SYSTEMS

General:

Cardiovascular:

Skin:

Respiratory:

Eyes:

Gastrointestinal:

Ears:

Genitourinary/Gynecological:

Nose/Mouth/Throat:

Musculoskeletal:

Breast: Heme/Lymph/Endo:

Neurological:

Psychiatry:

OBJECTIVE (Document PERTINENT systems only, Minimum 3 for problem focused, all systems for well child exam)

Weight: Height: BMI: BP: Temp: Pulse: Resp:

(Insert plotted growth chart below on all well child soap notes)

General appearance:

Skin:

HEENT:

Cardiovascular:

Respiratory:

Gastrointestinal:

Genitourinary:

Musculoskeletal:

Neurological:

Psychiatric:

Labs performed in office the day of visit:

Diagnosis (must complete this section and explain how all differential diagnoses were ruled in or ruled out)

Differential diagnoses:

1. Diagnosis, (ICD 10 code and reference):

2. Diagnosis, (ICD 10 code and reference):

3. Diagnosis (ICD 10 code and reference):

Diagnosis (ICD 10 code and reference):

Plan/therapeutics/diagnostics;

Education provided:

CPT Code:

Anticipatory guidance (well child visit only)