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ChatGPT Prompt: Act as a nurse practitioner and write a detailed SOAP note for a 9th grade student’s school physical exam. The child is healthy with no abnormal findings. No vaccines due; however, HPV recommended if patient hasn’t already started the series]. At the end, state that the patient is cleared for school and PE without restrictions. Please include the appropriate ICD-10 codes for the encounter.
SOAP Note – 9th Grade School Physical
S: Subjective
- Patient is a 14/15-year-old presenting for required school physical exam for high school entry.
- No current concerns. Denies recent illness, hospitalizations, or injuries.
- Denies chest pain, shortness of breath, palpitations, dizziness, or syncope with activity.
- No history of asthma, seizures, heart disease, concussions, or orthopedic issues.
- Family history negative for early sudden cardiac death.
- Appetite and sleep adequate; reports balanced diet and regular exercise.
- Normal bowel and bladder habits.
- Parent denies learning, developmental, or behavioral concerns.
- Medications: None.
- Allergies: NKDA.
- Immunizations: Up to date; no vaccines due at this visit. HPV vaccine series recommended if not yet initiated.
O: Objective
- General: Well-appearing adolescent, alert, no acute distress.
- Vital Signs: Within normal limits for age.
- Growth Parameters: Height, weight, BMI appropriate for age percentiles.
- HEENT: Normocephalic, atraumatic. PERRLA, EOMI intact. TMs clear. Oropharynx moist, no erythema/lesions. Dentition appropriate for age.
- Neck: Supple, no lymphadenopathy, no thyromegaly.
- Cardiovascular: RRR, no murmurs, rubs, or gallops. Peripheral pulses 2+ and equal.
- Respiratory: Lungs clear to auscultation bilaterally. No wheezes, rales, or rhonchi. Normal effort.
- Abdomen: Soft, non-tender, non-distended. No organomegaly or masses. Normal bowel sounds.
- Musculoskeletal: Full ROM, normal tone/strength. No swelling, deformity, or tenderness. Gait normal. Spine straight, no scoliosis.
- Skin: Warm, dry, intact, no rashes or concerning lesions.
- Neurologic: Alert and oriented. Normal strength, reflexes, coordination, and cranial nerves grossly intact.
- Vision/Hearing: Screening age-appropriate, within normal limits.
A: Assessment
- Z00.129 – Encounter for routine child health examination without abnormal findings
P: Plan
- Patient cleared for school, physical education, and extracurricular activities without restrictions.
- Encouraged balanced diet, regular exercise, adequate sleep, and routine dental care.
- Discussed anticipatory guidance for adolescence: puberty, mental health awareness, avoidance of substances (tobacco, vaping, alcohol, drugs), screen-time limits, internet/social safety, and healthy peer relationships.
- HPV vaccine series recommended if not yet started; discussed with parent/guardian and patient.
- Return annually for wellness exam or sooner if concerns arise.