What are the key components to include in a SOAP note for a pediatric patient with a history of trauma to the right arm and previous clavicle fracture, presenting with arm pain and tenderness?

Key Components for a Pediatric Trauma SOAP Note for Arm Injury

A comprehensive SOAP note for a pediatric patient with suspected arm fracture should include specific trauma-focused elements, with radiographic confirmation being the standard of care for diagnosis.

Subjective Section

• Document the exact mechanism of injury (how the fall occurred, height of fall, landing position) 1
• Record time of injury and evolution of symptoms since injury 1
• Document pain characteristics (location, severity using age-appropriate pain scale, aggravating/alleviating factors) 1
• Note any previous similar injuries, including history of clavicle fracture 1
• Document functional limitations (inability to use arm, decreased range of motion) 1
• Ask about associated symptoms (numbness, tingling, weakness) that might indicate neurovascular compromise 1
• Record parent/caregiver observations of the child's behavior since injury 1

Objective Section

• Vital signs including pain assessment 1
• Detailed examination of the entire arm from shoulder to fingers 1
• Document specific areas of tenderness, swelling, deformity, or ecchymosis 1
• Assess neurovascular status (document pulse strength, capillary refill time, sensation, motor function) 1
• Compare with uninjured contralateral arm 1
• Document range of motion (active and passive if appropriate) 1
• Note positioning of arm (how child is holding it, protective posturing) 1
• Document radiographic findings once available 1

Assessment Section

• Primary diagnosis based on clinical findings and radiographic results 1
• Differential diagnoses if radiographic results are pending 1
• Assessment of fracture stability if present 1
• Evaluation of growth plate involvement if applicable 1
• Assessment of neurovascular status 1
• Evaluation of pain control needs 1

Plan Section

• Specific treatment plan based on radiographic findings 1
• Immobilization details (type of splint/cast, positioning) 1
• Pain management strategy (specific medications with dosing based on weight) 1
• Patient/family education regarding care of injured extremity 1
• Follow-up recommendations (timing, specialty referral if needed) 1
• Return precautions (signs of neurovascular compromise, increased pain, etc.) 1
• Activity restrictions with specific timeframe 1

Common Pitfalls to Avoid

• Failing to examine the joints above and below the injury site 1
• Inadequate pain management for pediatric patients 1
• Missing growth plate injuries which may not be obvious on initial radiographs 1
• Incomplete neurovascular assessment documentation 1
• Failure to compare with the uninjured contralateral extremity 1
• Inadequate follow-up instructions for parents/caregivers 1

Remember that radiography is the preferred initial diagnostic modality for suspected fractures, with standard views including anteroposterior and lateral projections 1. For upper extremity injuries in children, special attention should be paid to growth plate involvement, which may require additional imaging or orthopedic consultation 1.