| Course | NUR 636 Primary Care of Infants, Children and Adolescents |
|---|---|
| Module | Module 4 |
| Paper type | SOAP note for an ADHD evaluation and first treatment |
| Length | About 1,010 words, 6 pages |
| Format | APA 7 student paper |
| School | Southern New Hampshire University |
| Program | MSN |
| Updated | September 2026 |
Free sample paper for NUR 636 Module 4
SOAP Note: Evaluation and Initial Treatment of Suspected ADHD in an Eight-Year-Old Boy
[Student Name]
Southern New Hampshire University
NUR 636: Primary Care of Infants, Children and Adolescents
Module Four SOAP Note
[Instructor Name]
[Date]
The organization, setting and figures below are a composite written as a model document. No real employer, client, colleague or patient is described.
SOAP Note: Evaluation and Initial Treatment of Suspected ADHD in an Eight-Year-Old Boy
Few chronic childhood conditions are as common as attention-deficit/hyperactivity disorder, and most affected children are diagnosed and treated in primary care. It is also easy to diagnose badly: on the basis of one parent's report, without school information, without looking for conditions that mimic or accompany it. This SOAP note documents the evaluation of an eight-year-old referred for attention problems. It argues that gathering standardized ratings from home and school, screening for sleep, learning and mood problems and applying the DSM-5 criteria through the American Academy of Pediatrics guideline leads to a diagnosis that can be trusted and a treatment plan suited to the child's age.
Subjective
Chief concern, from the parents: "His teacher says he can't focus, and homework is a battle every night."
History of present illness: Jayden is an eight-year-old boy in third grade. His teacher has sent notes home since first grade saying he does not finish classwork, gets out of his seat, calls out answers and interrupts other children. His parents describe losing jackets and homework, needing reminders for every step of the morning routine and homework sessions of two hours that end in tears. These behaviors are present at home, at school and at his grandmother's house. His grades are C's in reading and math, and his teacher says he understands concepts when working one-on-one. He falls asleep within 20 minutes, sleeps from 8:30 p.m. to 6:30 a.m., does not snore and wakes rested. He worries sometimes before tests but does not have daily worry, stomachaches or trouble separating. There are no motor or vocal tics.
Past history: born at term, normal development except for speech that was slightly late, resolved by age three. No head injury or seizures. No history of fainting, chest pain with exercise or palpitations. Family history: father had trouble in school and was never evaluated; no sudden cardiac death before age 50 or known heart rhythm disorders. Medications: none. Social: lives with both parents and a five-year-old sister; no recent moves or family stress.
Objective
Vital signs: blood pressure 98/60 mm Hg (50th percentile for age, sex and height), pulse 84, weight 26 kg (50th percentile), height 128 cm (50th percentile). Examination: well-appearing, active, frequently leaves the chair to look at the exam room equipment; responds appropriately to questions. Normal hearing and vision screening in clinic. Cardiac examination: regular rhythm, no murmur. Neurologic examination normal, with no tics observed.
Rating scales: on the parent NICHQ Vanderbilt, his mother marked seven inattentive items and six hyperactive-impulsive items at the two highest frequencies and noted problems with homework and family life. His teacher's form went further, with eight inattentive and seven hyperactive-impulsive items at those frequencies and problems with classwork and friendships. Screening items for anxiety and oppositional behavior are below threshold on both. The school reports reading at grade level on the most recent benchmark assessment.
Assessment
Attention-deficit/hyperactivity disorder, combined presentation. Jayden meets DSM-5 criteria: six or more symptoms of both inattention and hyperactivity-impulsivity for more than six months, several present before age 12, seen at home, at school and with family and clearly getting in the way of his learning and relationships. Under the 2019 AAP guideline, a primary care clinician who sees a school-aged child struggling in class with poor focus or impulsive behavior should test the DSM-5 criteria against reports from the family and the school and look for accompanying conditions before settling on the label (Wolraich et al., 2019). His normal sleep, absence of daily worry, grade-level reading, normal hearing and vision and absence of tics make the main alternatives and comorbidities less likely at this time, although a learning disorder cannot be fully excluded without formal educational testing.
Plan
For elementary-age children, the guideline pairs an FDA-approved medicine with behavioral help, meaning training for parents in managing behavior and support in the classroom, and it favors using both together (Wolraich et al., 2019). The MTA trial supports this approach: over 14 months, carefully managed medication was more effective than intensive behavioral treatment alone for core ADHD symptoms, and combined treatment offered some added benefits for related outcomes (MTA Cooperative Group, 1999). After discussion, the parents chose to start medication and behavior training together. Medication: methylphenidate extended release 18 mg each morning, increased in 18 mg steps at weekly intervals according to symptom response and side effects, up to a maximum appropriate for his weight. Cardiac screening: his personal and family cardiac history is negative and his examination is normal, so no ECG is needed before starting a stimulant, consistent with the AAP position that routine ECGs are not required in children without cardiac risk factors (Perrin et al., 2008). Behavior: referral to a parent training in behavior management group. School: a letter requesting evaluation for a Section 504 plan, with accommodations such as preferential seating and breaking assignments into steps.
Monitoring and Education
Follow-up by phone in one week and in clinic in four weeks, with repeat parent and teacher Vanderbilt follow-up scales before each dose change. Weight, height, blood pressure and pulse will be checked at each visit, since stimulants can reduce appetite and slightly raise heart rate and blood pressure. The parents were taught to give the medicine with breakfast, to watch for decreased appetite, trouble falling asleep, stomachaches or headaches and irritability as the dose wears off, and to keep the medication locked, since stimulants are controlled substances. Jayden was told, in words he understood, that the medicine helps his brain pay attention and that his job is to tell his parents if it makes him feel bad.
Conclusion
Jayden meets criteria for ADHD, combined presentation, with symptoms and impairment confirmed by ratings from home and school and no evidence so far of a condition that better explains them. Treatment follows the AAP guideline for his age: a stimulant titrated with ratings, parent behavior training and school supports, with growth and cardiovascular monitoring. Documenting each step of the evaluation makes the diagnosis defensible and the plan easy to follow.
References
MTA Cooperative Group. (1999). A 14-month randomized clinical trial of treatment strategies for attention-deficit/hyperactivity disorder. Archives of General Psychiatry, 56(12), 1073-1086. https://doi.org/10.1001/archpsyc.56.12.1073
Perrin, J. M., Friedman, R. A., & Knilans, T. K. (2008). Cardiovascular monitoring and stimulant drugs for attention-deficit/hyperactivity disorder. Pediatrics, 122(2), 451-453. https://doi.org/10.1542/peds.2008-1573
Wolraich, M. L., Hagan, J. F., Allan, C., Chan, E., Davison, D., Earls, M., Evans, S. W., Flinn, S. K., Froehlich, T., Frost, J., Holbrook, J. R., Lehmann, C. U., Lessin, H. R., Okechukwu, K., Pierce, K. L., Winner, J. D., & Zurhellen, W. (2019). Clinical practice guideline for the diagnosis, evaluation, and treatment of attention-deficit/hyperactivity disorder in children and adolescents. Pediatrics, 144(4), Article e20192528. https://doi.org/10.1542/peds.2019-2528
What the NUR 636 Module 4 instructions ask for
This NUR 636 SOAP note usually asks you to evaluate a child for a behavioral or developmental concern such as ADHD, document the diagnostic process and begin management. Expect a history that covers symptoms across settings, standardized rating scales from parents and teachers, screening for coexisting conditions, an assessment against DSM-5 criteria and a plan that reflects the guideline for the child's age group. Most submissions run three to five pages in APA 7. Show each diagnostic criterion with its evidence, explain why alternative conditions were considered, give a starting dose with a titration and monitoring plan and address school supports, since graders in this course check the diagnostic reasoning as closely as the prescription.
How this NUR 636 Module 4 soap note example is built
The sample evaluates a composite third grader with a year of unfinished classwork, calling out and homework battles. The history covers symptoms at home, school and a grandparent's house, sleep, anxiety, tics and cardiac history. Parent and teacher Vanderbilt scales both exceed six symptoms in each domain with impairment, and hearing, vision and reading are normal. The assessment walks through DSM-5 criteria using the Wolraich AAP guideline. The plan combines extended-release methylphenidate 18 mg with weekly titration, justified by the MTA trial, parent training and a Section 504 request, and explains, citing Perrin, why no ECG is needed. Monitoring and child-friendly education close the note, with safe storage of the controlled medication.
Where the NUR 636 Module 4 rubric puts the points
For NUR 636 behavioral SOAP notes, graders typically weigh the history across settings, use of validated rating scales from more than one informant, screening for comorbidities, application of diagnostic criteria, a plan consistent with the age-specific guideline, safety monitoring and APA 7 writing. The strongest notes document each DSM-5 criterion with evidence and explain why alternatives are less likely. Graders reward plans that combine medication with behavioral and school interventions for school-aged children, give specific titration and monitoring steps and address cardiac screening with a current position. Including the child's own understanding in education often earns credit for family-centered care and for developmentally appropriate communication.
NUR 636 Module 4 help: the mistakes that cost points
An ADHD note in NUR 636 is marked down when only one informant supports the diagnosis, when rating scales are named without results, when sleep problems, anxiety, learning disorders or hearing and vision problems are not considered or when medication is started without a titration or monitoring plan. Another frequent gap is ordering routine ECGs without cardiac risk factors or skipping the cardiac history entirely. Gather ratings from home and school, screen for mimics and comorbidities, document each criterion, follow the age-specific guideline, give dose, titration and monitoring and include school supports. If your case involves a preschooler or an adolescent, send the prompt and template for a note built on the recommendations for that age.
Get NUR 636 Module 4 written to your instructions
Send the NUR 636 case, your SOAP template and the rubric. The note you receive will document ratings from home and school, screen for mimics, apply DSM-5 criteria and the AAP guideline and give a titration and monitoring plan, within 24 to 48 hours, free the first time. The paper above is an original model document written by our desk, not a submitted student paper and not an official Southern New Hampshire University document.
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NUR 636 Module 4 questions, answered
Where can I find a free NUR 636 Module 4 SOAP Note sample?
Read the full note on this page: an ADHD evaluation in an eight-year-old with parent and teacher Vanderbilt ratings, comorbidity screening, DSM-5 criteria and first treatment under the AAP guideline.
How is ADHD diagnosed in primary care?
By confirming DSM-5 criteria with information from parents, teachers and other school staff, often using rating scales such as the Vanderbilt, and screening for conditions that mimic or accompany ADHD.
What does the AAP recommend for treating ADHD in children aged 6 to 11?
FDA-approved medication together with parent training in behavior management and behavioral classroom interventions, preferably both.
Is an ECG required before starting a stimulant?
Not routinely. The AAP position is that ECGs are not required for children without cardiac symptoms, a concerning family history or abnormal examination findings.
How should stimulant treatment be monitored?
With follow-up rating scales from parents and teachers before dose changes and checks of weight, height, blood pressure and pulse, plus review of appetite, sleep and mood.