PEDIATRIC SOAP NOTE

Patient: [Name]
Date of birth and age: [Date; age in years and months]
Date of visit: [Date]
Visit type: [Sick visit, recheck, or telehealth]
Accompanied by: [Caregiver and relationship to the child]
History from: [Caregiver, child, or both; interpreter if used]
Clinician: [Name, credentials]

SUBJECTIVE
Chief complaint: [Main concern, in the caregiver's or child's words]
History of present illness: [Onset, duration, course, associated symptoms, pertinent negatives]
Fever: [Days of fever, highest reading, how it was measured]
Intake and output: [Drinking and eating compared with usual; wet diapers or voids in 24 hours; vomiting or diarrhea]
Behavior: [Activity, play, sleep, irritability, whether consolable]
Child's account: [What the child reports, if old enough]
Treatments given: [Medicines given at home, with dose and time of the last dose]
Exposures: [Daycare or school, sick contacts, travel]
Background: [Birth history if relevant, chronic conditions, immunizations up to date per local schedule or not]
Medications: [Regular medicines with doses]
Allergies: [Drug, food, and other allergies, with reactions]

OBJECTIVE
Weight: [kg and lb, percentile, date weighed]
Vital signs: [Temperature with route, HR, RR, SpO2, BP if indicated, read against age-based ranges]
General appearance: [Alert, interactive, consolable, well or unwell appearing]
Hydration: [Mucous membranes, tears, capillary refill, fontanelle in infants]
Examination: [Findings by system for the complaint, plus ears, throat, chest, and skin in a febrile child]
Point-of-care tests: [Results, if done]

ASSESSMENT
Diagnosis: [Working diagnosis and the findings that support it]
Serious causes considered: [What was ruled out for this age, and how]
Severity: [Mild, moderate, or severe; degree of dehydration]

PLAN
Treatment: [Drug, mg/kg dose, calculated dose in mg and mL with the concentration, route, frequency, duration, daily maximum]
Supportive care: [Fluids, comfort measures, skin or nasal care]
Caregiver education: [What was explained, and the caregiver's understanding]
Return precautions: [Specific signs that need urgent review or emergency care]
Daycare or school: [When the child can return]
Follow-up: [When and with whom, or as needed]

Signed: [Clinician name, credentials, date and time]