Act as a nurse practitioner and write a detailed SOAP note for an 11–12 year old middle school student’s school physical exam. The child is healthy with no abnormal findings. Include that the patient is due for Tdap and Meningococcal vaccines today, the HPV vaccine series is recommended, and all other vaccines are up to date. 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 and immunizations.
Disclaimer:
NP AI Tools provides AI-generated drafts for educational and workflow support only. This content is not medical advice. Errors may occur, and all information must be carefully reviewed, edited, and verified by a licensed provider before use in patient care. Liability rests with the clinician who adopts and signs the documentation.
School physical requirements (including age and grade level) vary by state and local school district. Always verify your state’s regulations and school-specific requirements. Immunization recommendations are guided by the CDC schedule, which does not change by state.
SOAP Note – Middle School School Physical (11–12 Year Old)
S: Subjective
- Here for school physical required for middle school entry.
- No complaints. Denies recent illness, injury, syncope, chest pain, dyspnea with exertion, or concussion history.
- No history of asthma, seizures, cardiac disease, diabetes, or orthopedic problems.
- Family history negative for sudden cardiac death <50.
- Diet, sleep, bowel/bladder appropriate for age.
- Learning/behavior concerns: denied by parent and patient.
- Meds: none. Allergies: NKDA.
- Immunizations: Up to date except Tdap and MenACWY due today. HPV series recommended (not yet started).
O: Objective
- General: Well-appearing, cooperative, no acute distress.
- Vitals/Growth: WNL for age; height/weight/BMI appropriate percentiles.
- HEENT: NC/AT. PERRL, EOMI, conjunctiva clear. TMs pearly. OP moist, no erythema/lesions. Dentition appropriate.
- Neck: Supple, no LAD, no thyromegaly.
- Cardiovascular: RRR, no murmurs/rubs/gallops. Distal pulses 2+ and equal.
- Respiratory: CTAB, normal effort, no wheeze/rales/rhonchi.
- Abdomen: Soft, NTND, no HSM, normoactive BS.
- MSK: Full ROM, normal strength and tone, no tenderness/deformity. Spine straight, no scoliosis. Gait normal.
- Skin: Warm, dry, intact; no rashes/lesions.
- Neuro: Alert, oriented; CN grossly intact; normal reflexes/coordination.
- Vision/Hearing: Screening within normal limits for age.
A: Assessment
- Primary: Z00.129 – Encounter for routine child health examination without abnormal findings (used for school physical with normal exam).
- Additional: Z23 – Encounter for immunization (Tdap, MenACWY given/ due).
- (If you document counseling on HPV without administering today, you may also use Z71.85 – Immunization safety counseling.)
P: Plan
- Immunizations today: Tdap and MenACWY (MenACWY per state schedule). VIS provided; risks/benefits reviewed; tolerated well.
- Recommended: Initiate HPV vaccine [Add if started today]
- Clearance: Student is cleared for school attendance, PE, and sports without restrictions.
- Anticipatory guidance: nutrition, activity, screen-time limits, puberty/hygiene, injury prevention, and avoidance of tobacco/vaping/alcohol.
- Routine dental care and annual preventive visits encouraged.
- Return in 1 year for routine checkup or sooner PRN.