2. 'S - O' for the Adolescent 'SOAP' Note
____ yo here with (guardian?) for WCC. Healthy, well developed.
Confidential Time with Adolescent (SSHADDESS):
Vital Signs: temp (F/C), pulse, BP, RR, height (in/cm), wt (lb/kg)
1. Health Care Maintenance (HCM)
Sexual Health History
Have you ever had sex or come close to having sex?
- What are your plans for sex in the future? What do you think will make it the right time? (Discuss healthy relationships)
- Do you have sex with girls/guys or both?
- Do you have oral, vaginal, or anal sex?
- How old were you the 1st time you had sex?
- Do you enjoy sex?
- How many people have you had sex with in the last 3 months? In your life?
- When was the last time you had sex? (Emergency contraception candidate?)
- Do you (or your partner(s)) use anything to prevent getting pregnant or getting an STD? (Choosing a birth control method)
- Have you ever been pregnant? What choices did you make regarding that pregnancy?
- Have you ever been told that you had an STD?
- Have you or your partner(s) had sex with other people in the past year?
- Do alcohol or drugs ever affect your decision to have sex?
- Has anyone made you have sex when you didn't want to? (If yes, make mandated report)
- Have you ever traded sex for money, drugs, a place to stay or other things that you need? (If yes, make mandated report)
4. Topics To Consider
5. Adolescent Resources
- Adolescent Health Care 101, by Adolescent Health Working Group (AHWG) -- Of note, AHWG might be our favorite resource of adolescent health in the entire galaxy. If you have never check it out, please do yourself a huge favor and bookmark it.
- Bright Futures: Adolescence -- free guide file
- Choosing a Birth Control Method -- by Association of Reproductive Health Professionals (ARHP)
- Reproductive Health Access -- check out the clinical tools and fact sheets
- Sexual Growth & Development -- from Bright Futures
- AAP's patient/family handouts -- specifically for adolescence
- California Minor Consent and Confidentiality Laws
- Young Women's Health and Young Men's Health -- by Children's Boston
- Contraceptive Technology -- single best reference book for managing contraceptive needs ($10 pocket guide also available)
- Facts on American Teen's Sexual and Reproductive Health -- Guttmacher Institute, 2013
- National Adolescent and Young Adult Health Information Center (NAHIC) -- health statistics and information
- Improving the Health, Safety, and Well-Being of Young Adults, IOM (2013) -- SAHM Workshop Summary
- Rapid Assessment for Adolescent Preventative Services (RAAPS) -- preventative health screening tools