Example SOAP Note for a 4-Month-Old Well Child Check-Up
A comprehensive SOAP note for a 4-month-old well child check-up should include subjective information from parents, objective findings from examination, assessment of the child's development, and a preventive care plan.
Subjective
- Chief Complaint: "Here for 4-month well-child check-up"
- History of Present Illness: No acute concerns reported by parents 1
- Past Medical History:
- Birth history: Term infant, vaginal delivery, birth weight 7 lbs 8 oz
- No hospitalizations or surgeries since birth
- Prior screenings: Newborn metabolic screening normal 2
- Medications: Vitamin D supplements
- Allergies: None known
- Feeding: Exclusively breastfed or formula type/amount (specify which)
- Feeding well, no concerns with intake
- Not yet started on solid foods 1
- Sleep: Sleeping 5-6 hour stretches at night, 3-4 naps during the day
- Elimination: 6-8 wet diapers daily, regular soft bowel movements
- Development:
- Holds head up steadily when in prone position
- Smiles socially, makes eye contact
- Coos and babbles
- Reaches for objects 2
- Social History: Lives with both parents, no siblings, no pets
- Family History: No significant family history of genetic disorders or chronic diseases
Objective
- Vital Signs:
- Temperature: 98.6°F
- Heart Rate: 140 beats per minute
- Respiratory Rate: 30 breaths per minute
- Weight: (plot on growth chart)
- Length: (plot on growth chart)
- Head Circumference: (plot on growth chart) 1
- General: Alert, active, well-nourished, well-developed infant in no distress
- HEENT:
- Head: Normocephalic, anterior fontanelle open and flat
- Eyes: Red reflex present bilaterally, tracks objects, pupils equal and reactive to light 2
- Ears: Tympanic membranes intact bilaterally
- Nose: Patent nares, no discharge
- Mouth: Moist mucous membranes, no teeth erupted
- Neck: Supple, full range of motion
- Cardiovascular: Regular rate and rhythm, no murmurs
- Respiratory: Clear breath sounds bilaterally, no retractions
- Abdomen: Soft, non-tender, no masses, no hepatosplenomegaly
- Genitourinary: Normal external female/male genitalia, no inguinal hernias
- Musculoskeletal: Full range of motion of all extremities, good muscle tone
- Skin: No rashes, lesions, or birthmarks
- Neurologic:
- Age-appropriate tone and reflexes
- Lifts head and chest when prone
- Follows objects with eyes 2
- Development: Meets age-appropriate milestones per developmental surveillance 2
Assessment
- Healthy 4-month-old infant with normal growth and development
- Up-to-date on immunizations
- Age-appropriate feeding pattern
- No concerns identified during examination
Plan
Immunizations: Administer 4-month vaccines per CDC/ACIP schedule 3
- DTaP #2
- IPV #2
- PCV13 #2
- Hib #2
- Rotavirus #2
Nutrition:
- Continue breast milk or iron-fortified formula
- Delay introduction of solid foods until approximately 6 months of age
- Avoid juice before 12 months of age 1
Development:
- Continue to encourage tummy time to strengthen neck and upper body muscles
- Read and talk to infant daily to promote language development
- Engage in face-to-face interaction to promote social development 2
Safety:
- Continue rear-facing car seat in back seat of vehicle
- Never leave infant unattended on elevated surfaces
- Keep small objects away to prevent choking
- Maintain smoke-free environment 1
Sleep:
- Place infant on back to sleep
- Maintain safe sleep environment (firm mattress, no loose bedding or soft objects)
- Encourage consistent bedtime routine 1
Oral Health:
- Clean gums daily with soft cloth
- Avoid putting infant to bed with bottle 1
Screening:
Follow-up:
- Return for 6-month well-child visit
- Contact office for any concerns before next visit 1
Anticipatory guidance provided regarding:
All questions addressed and handouts provided on age-appropriate topics