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