Pediatric Endocrinology Follow-Up Note (SOAP)

Date: [Encounter date]
Patient: [Patient name], [DOB], [MRN]
Visit Type: Pediatric Endocrinology Follow-Up — [in-person / telehealth]
Clinician: [Clinician name, credentials]
Accompanied by: [Parent/guardian / patient alone / other]
Active Endocrine Problems: [Concise 1-line list of conditions being followed]

Subjective

Visit Focus: [Chief complaint or reason for follow-up]

[Interval history since last endocrine visit] (3–6 sentences covering: overall status, intercurrent illnesses or urgent events, hospitalizations, medication/device changes, adherence, and condition-relevant symptoms when present. Conclude with "ROS otherwise negative" or similar if no additional symptoms reported.)

[Adolescent confidential history if obtained] (Include only when applicable; handle sensitive content per institutional policy.)

Objective

Vitals/Growth: [Height, weight, BMI with percentiles or z-scores; growth velocity if growth-focused; BP with percentile if relevant] (Include brief trend with 2–3 prior data points when clinically important. State reason if not obtained, e.g., "BP not obtained—telehealth visit.")

Exam: [Focused endocrine-relevant findings: general appearance, thyroid exam, skin findings, Tanner staging as applicable] (Include pertinent positives and negatives only; do not enumerate normal systems. Note if exam components deferred and why.)

Data Reviewed: [Labs, imaging, and device data reviewed today with dates, key results with units, and source] (Clearly distinguish reviewed vs pending. For diabetes devices, include data source, date range, and key metrics such as time in range. For bone age, include chronologic age at study.)

Assessment

(Organize by problem in priority order. State explicitly if a listed problem was not addressed today.)

[Problem 1] — [stable / improving / worsening / uncontrolled]

[Brief clinical reasoning referencing key data and trends; relevant risks or complications; differential only when uncertainty affects management] (2–4 sentences.)

[Problem 2] — [stable / improving / worsening / uncontrolled]

[Clinical reasoning as above, or state "Not addressed today" with reason]

[Additional problems as needed]

[Clinical reasoning as above]

Plan

(Organize by problem, matching Assessment order. Include only applicable elements; omit empty categories.)

[Problem 1]

• Diagnostics: [Labs/imaging to order with timing; device upload schedule]
• Therapeutics: [Medication or device changes with complete dosing details; continue/hold instructions]
• Education: [Key counseling provided—sick-day rules, hypoglycemia management, stress dosing, etc.]
• Safety: [Condition-specific return precautions and red flags]

[Problem 2]

• [Include only applicable Plan elements for this problem]

[Additional problems as needed]

• [Include only applicable Plan elements]

Follow-Up: [Timing of next visit; pre-visit tasks such as labs, device uploads, growth measurements; contingencies if timing depends on results]