School-Age Children and Adolescents

Introduction:
If adolescents cannot trust that their health information will be both private and secure, they may not seek these services. —American Academy of Pediatrics

bjectives
This statement released by the American Academy of Pediatrics draws awareness to a topic of growing importance. According to the CDC’s National Center for Health Statistics, over 9% of school-age children and adolescents do not visit a health care provider regularly (U.S. Department of Health and Human Services, 2012). While this may be partially attributed to access to health care, concerns of privacy and trust also keep patients from obtaining necessary services. Patients are sometimes hesitant to share private information such as details of sexual activity or drug use with providers for fear that their parents will find out. In your role as the advanced practice nurse, you must be prepared to handle any provider-patient confidentiality issues that may arise with pediatric patients in clinical settings.
This week you explore the role of the provider regarding confidentiality between pediatric patients and their families. You also examine treatment and management strategies for school-age children and adolescents.
Assignment

Practicum: SOAP Note

SOAP Note submissions are a way to reflect on your Practicum experiences and connect these experiences to your classroom experience. SOAP Notes, such as the ones required in this course, are often used in clinical settings to document patient care.

Select a patient who you examined during the last 3 weeks. With this patient in mind, address the following in a SOAP Note:

Subjective: What details did the patient or parent provide regarding the personal and medical history? Include any discrepancies between the details provided by the child and details provided by the parent, as well as possible reasons for these discrepancies.

Objective: What observations did you make during the physical assessment? Include pertinent positive and negative physical exam findings.

Describe whether the patient presented with any growth and development or psychosocial issues.

Assessment: What were your differential diagnoses? Provide a minimum of three possible diagnoses. List them from highest priority to lowest priority. What was your primary diagnosis and why?

Plan: What was your plan for diagnostics and primary diagnosis? What was your plan for treatment and management? Include pharmacologic and non-pharmacologic treatments, alternative therapies, and follow-up parameters, as well as a rationale for this treatment and management plan.

Reflection notes: What was your “aha” (American Heart Association) moment?

What would you do differently in a similar patient evaluation?