Pediatric Cardiology Clinic Note (SOAP)

Visit type: [new referral / follow-up]

Date: [Date] — Clinic location: [Clinic location]

Referral source: [Referring clinician/service] — Referral question: [Specific question] (Include for new referrals only)

Historian(s): [Name(s) and relationship(s) to patient]

Interpreter: [Language] — [in-person / phone / video] (Omit line if no interpreter used)

Subjective

Chief Complaint

[Chief complaint in caregiver/patient wording]

History of Present Illness

[One-sentence patient summary: age (use months for infants), relevant cardiac history, and presenting concern]

[Narrative history with onset, duration, frequency, progression, triggers (exertion, stress, illness, positional change), alleviating factors; associated cardiopulmonary symptoms (dyspnea, cyanosis, diaphoresis, exercise intolerance, chest tightness, palpitations, presyncope/syncope); functional impact (exercise tolerance, school attendance, sports participation, infant feeding tolerance, growth concerns); prior evaluations and known key results (ECG, troponin, echo), treatments attempted and response]

• Key episodic details: (Include relevant bullets based on presenting complaint)
  • Murmur: [Who detected and when; new vs longstanding; symptoms suggesting pathologic etiology; fever/infection history if endocarditis considered]
  • Chest pain: [Quality, location, duration, frequency; relation to exertion; reproducibility; associated symptoms; triggers]
  • Syncope/presyncope: [Prodrome characteristics; posture; triggers; duration of loss of consciousness; witness description; injury; recovery time]
  • Palpitations: [Onset/offset pattern; perceived rate; duration; frequency; associated symptoms; caffeine/stimulant use; prior rhythm documentation]
  • CHD surveillance: [Interval events, procedures, medication adherence, activity tolerance compared to last visit]
• Red flags: [Exertional syncope or chest pain; syncope during exercise, without prodrome, or with injury; palpitations with syncope or chest pain; family history of sudden death, cardiomyopathy, or channelopathy] (Document explicitly when present; omit if none)

Past History

(For new patients, include baseline cardiac/medical history; for follow-ups, focus on interval changes)

• Cardiac history: [Diagnoses with dates; surgeries; catheterizations; prior imaging highlights; device history; CHD lesion summary and intervention timeline if applicable]
• Medical history: [Relevant non-cardiac comorbidities impacting risk or testing]
• Birth/neonatal history: [Gestational age, birth weight, NICU course, neonatal cardiac findings] (Include for infants or CHD patients)

Medications and Allergies

• Medications: [Medication — dose — route — frequency] (Include weight-based dosing rationale if changed; state explicitly if list uncertain or incomplete)
• Allergies: [Drug/agent — reaction type] (State "no known drug allergies" if none)

Family History

(Document explicitly even if negative or unknown)

• CHD in first-degree relatives: [present / absent / unknown]
• Cardiomyopathy: [present / absent / unknown]
• Channelopathy or unexplained seizures: [present / absent / unknown]
• Early pacemaker/ICD: [present / absent / unknown]
• Sudden unexplained death (especially young age): [present / absent / unknown]
• (If unknown, document reason: adopted, estranged, or limited family knowledge)

Social History

• Living situation: [Household members; caregiver arrangement if affecting adherence]
• School/activities: [Grade; attendance; activity level; sports participation and goals]
• Adolescent confidential screening: [Performed] (For adolescents; state performed without exposing sensitive details)
• Social determinants: [Transportation, insurance, or other barriers affecting care] (Include only if relevant)

Review of Systems

(Problem-focused; emphasize pertinent positives and negatives that inform assessment)

• Cardiovascular: [Pertinent findings]
• Respiratory: [Pertinent findings]
• Neurologic: [Pertinent findings]
• Constitutional: [Pertinent findings]

Objective

Vitals

• Height: [Value] [percentile]
• Weight: [Value] [percentile]
• BMI: [Value] [percentile]
• Heart rate: [Value bpm]
• Respiratory rate: [Value]
• Blood pressure: [Value] (Include site/limb/position if clinically relevant)
• Oxygen saturation: [Value%] [room air / supplemental oxygen]
• Temperature: [Value] (Include if obtained)

Physical Examination

• General: [Appearance; distress level; growth/nutrition impression]
• Respiratory: [Work of breathing; breath sounds]
• Cardiovascular:
  • Precordium/PMI: [Precordial activity; PMI location]
  • Rhythm: [regular / irregular]; Rate: [Value/description]
  • Heart sounds: [S1 and S2 characterization; splitting]
  • Murmur: [Timing, grade, location, radiation, quality, response to position/maneuvers] (Omit if no murmur)
  • Additional sounds: [Clicks, gallops, rubs, thrills] (Omit if none)
  • Pulses/perfusion: [Upper/lower extremity pulses; symmetry; capillary refill; extremity warmth and color; edema]
• Abdomen: [Hepatomegaly; ascites; tenderness] (Include when relevant)
• Extremities: [Edema; clubbing; cyanosis; perfusion]
• Skin: [Cyanosis; clubbing; relevant findings]
• Neurologic: [Alertness; focal deficits] (Include if relevant to syncope/presyncope)

Data and Studies Reviewed

(Omit this entire section if no data were reviewed or ordered; include only subsections with content)

Outside records: [Source and date] — [Clinically relevant findings]

ECG: [Date, today/prior] — [Rate; rhythm; axis; PR, QRS, QTc intervals; hypertrophy patterns; preexcitation; ectopy; ST-T changes] (Note if independent interpretation performed)

Echocardiogram: [Date and type] — [Key structural findings; ventricular function; gradients; chamber sizes; pericardial effusion; coronary origins if relevant; comparison to prior]

Ambulatory monitoring: [Dates and duration] — [Arrhythmia burden; symptom-triggered events; symptom-rhythm correlation; overall impression]

Other studies: [Exercise testing / labs / imaging / genetic testing / device interrogation] — [Date and key results]

Assessment and Plan

[Summary statement: referral question or main concern; key supporting data from history, exam, and studies; overall clinical impression and risk framing]

[Problem 1] — [new / established], [stable / worsening / improved / controlled / uncontrolled]

Assessment: [Most likely diagnosis with brief justification; key differentials with pertinent positives and negatives; risk stratification statement]

• Diagnostics: [Tests ordered with rationale explaining why this test now; why alternatives deferred] (For echo or monitoring, tie indication to specific clinical features)
• Treatment: [Medications with dose and frequency; nonpharmacologic measures as applicable]
• Activity and sports: [Clearance or restrictions with rationale]
• Education: [Counseling points delivered; warning signs reviewed]
• Follow-up: [Interval and setting; contingencies for earlier return]
• Coordination: [Communication with referring clinician, PCP, school, athletics, or other specialists]

[Problem 2] — [new / established], [status]

Assessment: [Brief assessment and risk statement]

• Plan: [Diagnostics; treatment; activity; education; follow-up; coordination]

(Add additional problems as needed using same structure)

Follow-Up and Safety Precautions

• Return: [Interval] — [cardiology clinic / echo with clinic / EP clinic]
• Pending results: [Who will contact family; expected timeframe]
• Return precautions: [Syncope with exertion; chest pain with exertion; sustained palpitations with presyncope; worsening dyspnea or cyanosis] (List specific precautions discussed)

Clinician signature: [Name, credentials] — Date: [Date]