What is the proper format and content for a pediatric SOAP (Subjective, Objective, Assessment, Plan) note?

Pediatric SOAP Note Format and Content

A pediatric SOAP note must include four structured sections—Subjective, Objective, Assessment, and Plan—with pediatric-specific elements including patient demographics, age-appropriate vital signs, developmental milestones, family-centered information, and growth parameters documented systematically. 1

Essential Components by Section

Subjective Section

• Document the chief complaint in the patient's or caregiver's own words, capturing the primary reason for the visit as stated by the family 1
• Record comprehensive medical history including all allergies, previous adverse drug reactions, and complete medication history (prescription medications, over-the-counter medications, herbal supplements) 1, 2
• Include relevant past medical history with specific diseases, physical abnormalities, previous hospitalizations, and seizure disorders 2
• For females of childbearing age, document pregnancy status 2
• Capture developmental history and age-appropriate milestones relevant to the visit 3
• Document family and social history, utilizing linkages to avoid redundancy when information is already recorded 3

Objective Section

• Record all vital signs: heart rate, blood pressure, respiratory rate, room air oxygen saturation, and temperature 1, 2
• Document age and weight, which are critical pediatric parameters 2
• If vital signs cannot be obtained due to patient non-cooperation, explicitly document this fact 3, 2
• Include focused physical examination findings relevant to the patient's condition and presenting complaint 1, 2
• Record all laboratory values, diagnostic test results, and other measurable objective data 1
• For age-specific visits, document developmental surveillance findings including achievement of age-appropriate milestones 4

Assessment Section

• Document all positive findings noted during evaluation and formulate differential diagnoses 1, 2
• Include problem identification with clinical reasoning that synthesizes information from Subjective and Objective sections 5
• For hospitalized patients, include a note documenting chart review 2
• Record diagnostic impressions with supporting rationale 6

Plan Section

• Document specific management plans for each identified problem, including both drug therapy and non-drug therapy interventions 6
• Include patient/family education plans and follow-up arrangements 6
• For prescribed medications, attach a copy of the prescription or detailed note describing medication content, dosing, route, and timing 2
• Document instructions given to the responsible caregiver regarding medications and home care 2
• Record planned diagnostic workups and treatment interventions 7

Pediatric-Specific Documentation Requirements

Age-Based and Developmental Considerations

• EHR documentation must support age-based, longitudinal, and family-centered care values specific to pediatrics 3
• Include developmental surveillance at appropriate intervals, assessing milestones such as motor skills, language development, and social interaction 4
• Document growth parameters using appropriate pediatric growth charts 3

Family-Centered Elements

• Record patient demographics including name, address, telephone number, and additional contact information for caregivers 1, 2
• Include the name of the patient's personal care provider or medical home 2
• Document family dynamics and caregiver concerns as they relate to the child's health 3

Time-Based Documentation for Procedures

• When sedation or procedures are performed, maintain a time-based record documenting drug name, route, site, time of administration, dosage, and patient effect 3, 2
• Record continuous monitoring data including level of consciousness, responsiveness, and vital signs throughout the procedure 3, 2
• Document "time out" confirmation of patient name, procedure, and site 2

Documentation Best Practices

Completeness and Accuracy

• Use a systematic approach to avoid overlooking important elements, ensuring all illnesses and injuries are documented consistently with state or local licensing requirements 1
• Verify that all documented information is factual and objective before finalizing 1
• Review notes for errors and omissions prior to completion 1
• Always sign and date the note—failure to sign is a common and significant documentation error 7

Clarity and Organization

• Keep documentation simple, straightforward, and comprehensible using appropriate font type and layout 1
• Use standardized templates that support pediatric-specific needs while allowing flexibility for individual patient circumstances 3
• Avoid redundancy by utilizing data linkages for family and social history 3

Quality Improvement

• Regularly review documentation practices to identify areas for improvement 1
• Participate in peer review of documentation to maintain quality standards 1
• Engage clinical informaticists to bridge gaps between frontline clinicians and health information technology systems 3

Common Pitfalls to Avoid

• Never omit documentation when vital signs cannot be obtained—explicitly state patient non-cooperation 2
• Do not fail to document medication history that could interact with planned treatments 2
• Avoid inadequate documentation of allergies and previous adverse drug reactions 2
• Do not place physical examination findings in the Subjective section—this is a frequent error that compromises note organization 7
• Never omit your signature and credentials on the completed note 7
• Avoid failing to document baseline health status for comparison during ongoing treatment 2
• Do not neglect to document non-drug therapy plans alongside pharmacological interventions 6