How to Write Clinical Notes on Teenagers

Clinical notes are the official record of an interaction with a patient. The information helps you track their progress, growth and treatment. SOAP is an acronym commonly used to guide clinical notes. It stands for Subjective, Objective, Assessment, Plan. Use this as your guide for recording your interactions with a patient.

Things You'll Need

• Patient chart

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Instructions

• 1

  Note the affect of the teenager. Affect is the outward appearance of emotion. For example, a flat affect indicates the teenager is not expressing their inward feelings for others to interpret and see. If the patient expresses their mood, but it does not match their affect, write it in the clinical notes. This is part of the "S."

• 2

  Answer questions in the clinical notes about their mental health, status with school friends, ability to function according to their developmental stage and relationships with their family. A psycho-social assessment observes the teens personal understanding of themselves (psycho) and their interactions with the world around them (social). Teenage years are a period of tremendous growth, both physically, mentally, emotionally and socially. Familial relationships are often stressed as the teenager anticipates a key transition period in their life. This is part of the "S" also.

• 3

  Take the patient's vitals. Vitals are blood pressure, pulse, respiration, temperature and pain. Record these each time the patient is seen. If the patient is in distress, track the vitals more often, noting any numbers out of the ordinary. Review the patient's previous lab work, admissions to the clinic and medications. This is part of the "O."

• 4

  Record the appearance of the teenager. Note their physical condition, such as bruises, track marks, skin durability and strength, sores and cuts. Teenagers are at risk for higher rates of domestic violence, rape and abuse. This age group also has high rates of motor vehicle accidents. This is the "S" or "O" section depending on the measurability of the data versus your interpretation of their appearance.

• 5

  Using the information gathered, record your diagnosis in the clinical notes. As more evidence is gathered, the diagnosis and plan will change. Note which body systems are involved in the complaint. This is the "A."

• 6

  Based on the assessment, a clinician will review the patient's case and decide on a treatment plan. A treatment plan may include monitoring, medications, consultations with other medical staff, advising and education. The entire health care team should be aware of the plan and their responsibilities to the patient. This is the "P."