Pediatric SOAP Note
Name: Date:
Sex: Age/DOB/Place of Birth:
SUBJECTIVE Historian: Present Concerns/CC: Reason given by the patient for seeking medical care “in quotes” Child Profile: (Sexual History (If appropriate); ADLs (age appropriate); Safety Practices; Changes in daycare/school/after-school care; Sports/physical activity; Developmental Hx) HPI: (must include all components) Medications: (List with reason for med ) PMH: Allergies: Medication Intolerances: Chronic Illnesses/Major traumas: Hospitalizations/Surgeries: Immunizations: Family History (Please identify all immediate family) Social History Education level, occupational history, current living situation/partner/marital status, substance use/abuse, ETOH, tobacco, and marijuana. Safety status ROS General
Cardiovascular
Skin
Respiratory
Pediatric SOAP Note
Eyes
Gastrointestinal
Ears
Genitourinary/Gynecological
Nose/Mouth/Throat
Musculoskeletal
Breast
Neurological
Heme/Lymph/Endo
Psychiatric
OBJECTIVE (plot height/weight/head circumference along with noting percentiles) Attach growth chart Weight
Temp BP
Height
Pulse Resp
General Appearance and parent‐child interaction
Skin HEENT Cardiovascular Respiratory Gastrointestinal Breast Genitourinary
Pediatric SOAP Note
*ALL references must be Evidence Based (EB)
Musculoskeletal Neurological Psychiatric In-house Lab Tests – document tests (results or pending)
Pediatric/Adolescent Assessment Tools (Ages & Stages, etc) with results and rationale For adolescents (HEADSSSVG Assessment)
Diagnosis Include at least three differential diagnoses with ICD-10 codes. (Includes Primary dx and 2 differentials) Document Evidence based Rationale for ROS and each differential with pertinent positives and
negatives Primary diagnosis
Is #1 on list of differentials Evidence for primary diagnosis should be supported in the Subjective and Objective exams.
PLAN including education
Plan: Treatment plan should be for the Primary Diagnosis and based on EB literature. Include EB rationale for all aspects of your treatment plan:
Vaccines administered this visit Vaccine administration forms given Medication-amounts and mg/kg for medications Laboratory tests ordered Diagnostic tests ordered Patient education including preventive care and anticipatory guidance Non-medication treatments Follow-up appointment with detailed plan of f/u
