Instructions for ChatGPT: Act as a nurse practitioner and write a detailed kindergarten school physical SOAP note without immunizations needed on a healthy child without abnormal findings. Patient may participate in school sports and PE without restrictions. Include ICD code in assessment and plan.
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.
SOAP Note – Kindergarten School Physical
S: Subjective
- Patient is a [5/6]-year-old child presenting for a routine school physical.
- No current complaints. Parent denies any history of chronic medical conditions, recent illness, hospitalizations, or injuries.
- No developmental concerns. Patient eats a balanced diet, sleeps well, and is active at home.
- No vision, hearing, or behavioral concerns reported.
- No known drug allergies.
- Medications: None.
- Immunizations: Up to date. No additional vaccines required today.
O: Objective
- General: Well-appearing, cooperative child, in no acute distress.
- Vital Signs: Within normal limits for age.
- Growth Parameters: Height, weight, and BMI appropriate for age and percentile range.
- HEENT: Normocephalic, atraumatic. Pupils equal, round, reactive to light and accommodation. Extraocular movements intact. Tympanic membranes clear bilaterally. Oropharynx moist without erythema or lesions. Dentition appropriate for age.
- Neck: Supple, no lymphadenopathy or thyromegaly.
- Cardiovascular: Regular rate and rhythm, no murmurs, gallops, or rubs. Pulses palpable and symmetric.
- Respiratory: Clear to auscultation bilaterally, no wheezes, rales, or rhonchi. No increased work of breathing.
- Abdomen: Soft, non-tender, no hepatosplenomegaly, normal bowel sounds.
- Musculoskeletal: Full range of motion in all extremities, no deformities, swelling, or tenderness. Gait normal and age-appropriate. Spine straight without scoliosis.
- Skin: Warm, dry, intact, no rashes or lesions.
- Neurologic: Alert and oriented, normal tone, strength, coordination, and reflexes. Cranial nerves grossly intact by observation.
- Vision & Hearing: Screening normal for age.
A: Assessment
- Z00.129 – Encounter for routine child health examination without abnormal findings
- Healthy child presenting for kindergarten school physical.
- Growth and development appropriate for age. Immunizations current.
P: Plan
- Patient cleared for school attendance, physical education, and sports without restrictions.
- Encourage healthy diet, regular physical activity, routine dental care, and annual check-ups.
- Vision and hearing screenings completed and normal.
- Parent advised to return for annual well child exam or sooner if concerns arise.
- Anticipatory guidance provided regarding safety (seatbelt/booster use, helmet use, stranger safety, screen time limits, and sleep hygiene).