J06.9 | Acute upper respiratory infection, unspecified
J30.9 | Allergic rhinitis, unspecified
Patient 13 months old comes in with mom for complains of wet cough that started on 5/23 with decreased activity, voice changed and decreased appetite . Patient voice change ,activity level and appetite resolved. Patient started to have nasal congestion yesterday 5/28/25. Patient mom denies any fever, rash, signs of ear pain.
A: nasal congestion noted, ears TMs pearly clear BL,
throat not irritated, BL tonsils +1
RUL, RML, RLL, LUL, LLL lung fields clear
TX: Increase fluid intake over the counter ibuprofen to treat fever and body aches
F/U in 9 months for annual exam or PRN if symptoms worsen
Subjective, Objective, Assessment, Plan (SOAP) Notes
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)
References:
