MOTHER SOAP NOTE
Subjective:
- Reasons for visit: Mother is seeking assistance with breastfeeding difficulties, specifically latching issues and concerns about milk supply.
- Duration/timing/location/quality/severity/context of complaint: Latching difficulties have been present since birth, with the baby frequently detaching during feeds. Mother reports pain during feeding, rated as a 7/10. The pain is located in the nipples and is described as sharp and burning.
- List anything that worsens or alleviates the symptoms, including self-treatment attempts and their effectiveness: Pain is worsened by poor latch and prolonged feeding sessions. Mother has tried nipple shields, which provided some temporary relief but did not resolve the underlying issue.
- Progression: Symptoms have remained consistent since birth, with no significant improvement despite the use of nipple shields.
- Impact on daily activities: Mother reports feeling stressed and anxious about feeding, impacting her ability to rest and care for the baby.
- Associated symptoms: Mother reports engorgement and occasional mastitis symptoms.
Past Medical History:
- Contributing factors including past medical and surgical history, investigations, treatments, relevant to the reasons for visit and chief complaints: Mother had a vaginal delivery with no complications. No previous history of breast surgery.
- Social history that may be relevant to the reasons for visit and chief complaints: Mother is a stay-at-home parent, supported by her partner.
- Family history that may be relevant to the reasons for visit and chief complaints: No family history of breastfeeding difficulties.
Objective:
- Vitals signs: Mother's temperature is 37.2°C, pulse 80 bpm, blood pressure 120/80 mmHg.
- Physical or mental state examination findings, including system specific examination(s): Breast examination reveals engorgement and cracked nipples. Baby's oral exam reveals no structural abnormalities.
Assessment:
- Likely diagnosis: Poor latch, nipple trauma, possible insufficient milk transfer.
Plan:
- Treatment planned: Provide education on proper latch techniques, including positioning and attachment. Recommend frequent feeding and pumping to stimulate milk production. Recommend application of lanolin cream to nipples.
- Relevant other actions such as counselling, referrals etc: Refer to a lactation support group.
- Education provided on topics, and handouts given, weblinks, and videos sent: Provided handouts on proper latch techniques and breastfeeding positions. Sent links to La Leche League International.
- Any patient or family education provided, including discharge planning or instructions for home care: Instructed mother on signs of effective feeding and how to monitor baby's weight gain. Provided instructions on hand expression and pumping.
Follow up:
- list reasons for a return visit: To assess latch, milk supply, and nipple healing.
- date for a return visit: 8 November 2024
INFANT SOAP NOTE
Subjective:
- Reasons for visit, chief complaints such as requests, symptoms etc: Difficulty latching, poor weight gain.
- Duration/timing/location/quality/severity/context of complaint: Difficulty latching since birth. Poor weight gain over the past week.
- List anything that worsens or alleviates the symptoms, including self-treatment attempts and their effectiveness: Worsened by poor latch. Nipple shields provided temporary relief.
- Progression: No improvement in latch or weight gain.
- Impact on daily activities: Baby is fussy and not sleeping well due to hunger.
- Associated symptoms: Fussiness, infrequent wet diapers.
Past Medical History:
- Contributing factors including past medical and surgical history, investigations, treatments, relevant to the reasons for visit and chief complaints: Born at term, no complications.
Objective:
- Vitals signs: Weight: 6 lbs 10 oz (decreased from 7 lbs at birth), no fever.
- Physical or mental state examination findings, including system specific examination(s): Oral exam: No structural abnormalities. Observed latch: Shallow latch.
Assessment:
- Likely diagnosis: Poor latch, insufficient milk intake.
Plan:
- Treatment planned: Observe feeding, assess latch, and provide education on proper latch techniques. Recommend frequent feeding and pumping to stimulate milk production.
- Education provided on topics, and handouts given, weblinks, and videos sent: Provided handouts on proper latch techniques and breastfeeding positions.
- Any patient or family education provided, including discharge planning or instructions for home care: Instructed mother on signs of effective feeding and how to monitor baby's weight gain. Provided instructions on hand expression and pumping.
Follow up:
- list reasons for a return visit: To assess latch, milk supply, and nipple healing.
- date for a return visit: 8 November 2024
(Please separate out the 2 patients in this visit Mother/parent and Infant/baby, if you are unsure which
soap to put information under, please use the mother's)
MOTHER SOAP NOTE
Subjective:
- [Mention reasons for visit, chief complaints such as requests, symptoms etc] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)
- [Mention Duration/timing/location/quality/severity/context of complaint] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)
- [Mention List anything that worsens or alleviates the symptoms, including self-treatment attempts and their effectiveness] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)
- [Progression: Mention describe how the symptoms have changed or evolved over time] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)
- [Previous episodes: Mention detail any past occurrences of similar symptoms, including when they occurred, how they were managed, and the outcomes] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)
- [Mention Impact on daily activities: explain how the symptoms affect the patient's daily life, work, and activities.] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)
- [Associated symptoms: Mention any other symptoms (focal and systemic) that accompany the reasons for visit & chief complaints] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)
Past Medical History:
- [Mention Contributing factors including past medical and surgical history, investigations, treatments, relevant to the reasons for visit and chief complaints]
- [Mention Social history that may be relevant to the reasons for visit and chief complaints.] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)
- [Mention Family history that may be relevant to the reasons for visit and chief complaints.] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)
- [Mention Exposure history] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)
- [Mention Immunization history & status] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)
- [Other: Mention Any other relevant subjective information] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)
Objective:
- [Vitals signs (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)]
- [Physical or mental state examination findings, including system specific examination(s) (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)]
- [Investigations with results] (you must only include completed investigations and the results of these investigations have been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise you must leave investigations with results blank. All planned or ordered investigations must not be included under Objective; instead all planned or ordered investigations must be included under Plan.)
Assessment:
- [Likely diagnosis (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)]
- [Differential diagnosis (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)]
-[Nursing diagnosis or identified needs based on the subjective and objective data (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)]
- [Prioritization of patient care needs (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)]
Plan:
- [Investigations planned (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)]
- [Treatment planned (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)]
- [Relevant other actions such as counselling, referrals etc (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)]
-[Care plan adjustments or interventions planned during the visit, including wound care, mobility assistance, patient education, etc. (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)]
- [Collaboration with other healthcare team members (mention planned discussions or interventions involving physicians, physical therapists, social workers, etc.) (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)]
-[Education provided on topics, and handouts given, weblinks, and videos sent (mention if available)
-[Additional Notes:(mention only if available)]
- [Any patient or family education provided, including discharge planning or instructions for home care (mention if available)]
- [Communication with patient and family about care decisions, concerns, and preferences (mention if available)]
- [Any safety concerns or incidents reported (mention if available)]
Follow up:
-[list reasons for a return visit (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)]
-[date for a return visit (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)]
INFANT SOAP NOTE
Subjective:
- [Mention reasons for visit, chief complaints such as requests, symptoms etc] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)
- [Mention Duration/timing/location/quality/severity/context of complaint] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)
- [Mention List anything that worsens or alleviates the symptoms, including self-treatment attempts and their effectiveness] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)
- [Progression: Mention describe how the symptoms have changed or evolved over time] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)
- [Previous episodes: Mention detail any past occurrences of similar symptoms, including when they occurred, how they were managed, and the outcomes] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)
- [Mention Impact on daily activities: explain how the symptoms affect the patient's daily life, work, and activities.] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)
- [Associated symptoms: Mention any other symptoms (focal and systemic) that accompany the reasons for visit & chief complaints] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)
Past Medical History:
- [Mention Contributing factors including past medical and surgical history, investigations, treatments, relevant to the reasons for visit and chief complaints]
- [Mention Social history that may be relevant to the reasons for visit and chief complaints.] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)
- [Mention Family history that may be relevant to the reasons for visit and chief complaints.] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)
- [Mention Exposure history] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)
- [Mention Immunization history & status] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)
- [Other: Mention Any other relevant subjective information] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)
Objective:
- [Vitals signs (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)]
- [Physical or mental state examination findings, including system specific examination(s) (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)]
- [Investigations with results] (you must only include completed investigations and the results of these investigations have been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise you must leave investigations with results blank. All planned or ordered investigations must not be included under Objective; instead all planned or ordered investigations must be included under Plan.)
Assessment:
- [Likely diagnosis (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)]
- [Differential diagnosis (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)]
-[Nursing diagnosis or identified needs based on the subjective and objective data (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)]
- [Prioritization of patient care needs (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)]
Plan:
- [Investigations planned (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)]
- [Treatment planned (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)]
- [Relevant other actions such as counselling, referrals etc (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)]
-[Care plan adjustments or interventions planned during the visit, including wound care, mobility assistance, patient education, etc. (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)]
- [Collaboration with other healthcare team members (mention planned discussions or interventions involving physicians, physical therapists, social workers, etc.) (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)]
-[Education provided on topics, and handouts given, weblinks, and videos sent (mention if available)
-[Additional Notes:(mention only if available)]
- [Any patient or family education provided, including discharge planning or instructions for home care (mention if available)]
- [Communication with patient and family about care decisions, concerns, and preferences (mention if available)]
- [Any safety concerns or incidents reported (mention if available)]
Follow up:
-[list reasons for a return visit (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)]
-[date for a return visit (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)]
(Never come up with your own patient details, assessment, plan, interventions, evaluation, and plan for continuing care - use only the transcript, contextual notes or clinical note as a reference for the information include in your note.)
