Is SOAP (Subjective, Objective, Assessment, and Plan) note suitable for pediatric ear assessment?

SOAP is Not Optimal for Pediatric Ear Assessment

While SOAP notes can be used for documenting pediatric ear assessments, they are not the most suitable format as they lack the specific structured elements needed for comprehensive pediatric audiological evaluation. 1, 2

Age-Appropriate Assessment Methods

Pediatric ear assessment requires specialized, age-appropriate testing methods that go beyond the standard SOAP format:

• Newborns to 9 months:

  • Evoked Otoacoustic Emissions (OAEs) - 10-minute test using a small probe in the ear canal
  • Automated Auditory Brainstem Response (ABR) - 15-minute test using electrodes on the child's head 1, 2

• 9 months to 2.5 years:

  • Visual Reinforcement Audiometry (VRA) - 15-30 minute test conditioning the child to associate sounds with visual reinforcers 1, 2

• 2.5 to 4 years:

  • Play audiometry - 15-30 minute test where children respond to sounds through play activities 1, 2

• 4 years and older:

  • Conventional audiometry - Child raises hand when stimulus is heard 1, 2

Specialized Testing Components Required

Pediatric ear assessment requires specific components not typically captured in standard SOAP format:

• Tympanometry: Measures middle ear function and can identify effusion

  • Classified as types A (normal), B (flat, abnormal), or C (negative pressure) 3
  • High-frequency probe tone (1000 Hz) needed for infants younger than 6 months 1

• Objective hearing thresholds: Testing at specific frequencies (500,1000,2000,4000 Hz) with a fail criterion of >20 dB HL 1, 2

• Ear-specific results: Each ear must be tested individually using insert earphones when possible 1

Diagnostic Accuracy Considerations

Standard clinical examination without specialized testing has significant limitations:

• Studies show only slight to fair agreement (kappa 0.20-0.32) between pediatric residents' clinical examinations and tympanometry 4
• Even otolaryngologists achieve only fair agreement (kappa 0.32) with tympanometry 4
• Pneumatic otoscopy, when properly performed, has sensitivity of 94% and specificity of 80% for detecting middle ear effusion, but requires specific training 5

Recommended Documentation Approach

Instead of standard SOAP format, pediatric ear assessment documentation should include:

1. Specific audiologic test results based on age-appropriate methods
2. Quantitative measurements of hearing thresholds at multiple frequencies
3. Tympanometry results with type classification
4. Ear-specific findings for each ear separately
5. Risk factor assessment for hearing loss (e.g., family history, syndromes, infections)

Implementation Challenges

General practitioners face barriers to implementing comprehensive ear assessments:

• Tympanometry is preferred over pneumatic otoscopy due to ease of use and interpretation, but cost is a significant barrier 6
• Pneumatic otoscopy requires more training and is considered more difficult to master 6
• Testing environment must be quiet with minimal distractions, which may be difficult in typical clinical settings 1, 2

For optimal pediatric ear assessment, specialized documentation formats that incorporate these specific audiologic testing components are more appropriate than the standard SOAP note format.