Pediatric SOAP Note template
. See bellow the attach document how to completed it.
Name: |
Date: |
Sex: |
Age/DOB/Place of Birth: |
SUBJECTIVE |
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Historian: Present Concerns/CC: Reason given by the patient for seeking medical care “in quotes” |
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Child Profile: (Sexual History (If appropriate); ADLs (age appropriate); Safety Practices; Changes in daycare/school/after-school care; Sports/physical activity; Developmental Hx) |
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HPI: (must include all components) |
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Medications: (List with reason for med ) |
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PMH: Allergies: Medication Intolerances: Chronic Illnesses/Major traumas: Hospitalizations/Surgeries: Immunizations: |
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Family History ( |
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Social History |
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ROS |
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General |
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Cardiovascular |
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Skin |
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Respiratory |
Pediatric SOAP Note
Eyes |
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Gastrointestinal |
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Ears |
Genitourinary/Gynecological |
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Nose/Mouth/Throat |
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Musculoskeletal |
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Breast |
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Neurological |
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Heme/Lymph/Endo |
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Psychiatric |
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OBJECTIVE (plot height/weight/head circumference along with noting percentiles) |
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Weight |
Temp |
BP |
Height |
Pulse |
Resp |
General Appearance and parent‐child interaction |
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HEENT |
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Genitourinary |
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 · 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 |
*ALL references must be
Evidence Based (EB)