Pediatric Gastroenterology Outpatient Note (SOAP)

Date of Service: [Date of service]

Patient: [Patient name, age, sex] (Use age in years and months for pediatrics.)

Encounter Type: [new / established]; [in-person / telehealth]

Clinician: [Clinician name, credentials]

Historian: [patient / parent–caregiver / other] (State interpreter use explicitly; e.g., "No interpreter used" or "[Language] interpreter used.")

Subjective

Chief Complaint: [Chief complaint in patient or caregiver words] (For follow-ups, pair with known diagnosis. If unclear, use "Reason for visit:" as fallback. Never omit.)

History of Present Illness: [Narrative summary] (Begin with a one-sentence summary restating the chief complaint and patient context. Include onset, duration, course, severity, and functional impact on school, sleep, and growth. Add associated GI symptoms as relevant and explicitly address red flags evaluated or present: weight loss, GI bleeding, bilious emesis, nocturnal symptoms, growth faltering. Summarize prior therapies and response. For infants or feeding concerns, incorporate feeding history: breast/formula type, volumes, texture tolerance. For constipation/diarrhea, document stool frequency and consistency using Bristol-type descriptors. Include relevant triggers, diet patterns, and exposure history only when clinically pertinent. If history is limited, state why.)

Pertinent History: (Include only clinically relevant items; omit unused bullets.)

• Past Medical History: [Relevant conditions/comorbidities]
• GI Procedures: [Endoscopy/colonoscopy dates and key findings]
• Medications/Supplements: [Current GI-related meds, laxatives, supplements with doses]
• Allergies: [Allergen and reaction type]
• Family History: [IBD, celiac, colon cancer, eosinophilic disease, other pertinent conditions]

Review of Systems: [Focused ROS] (Pertinent positives and negatives emphasizing GI, growth, and constitutional symptoms. Add other systems only when relevant to the differential. If not obtained, state reason.)

Objective

Vitals/Growth: [Weight, height/length, BMI with percentiles or z-scores] (For telehealth, note source of measurements or state not obtained. Add trajectory statement if growth is a concern, e.g., "Weight percentile downtrending from [x] to [y] over [time].")

Exam: [Pertinent findings by system] (Prioritize general appearance, hydration status, and abdominal exam. Include oropharynx, skin, perianal, or other systems only when clinically indicated. Document only systems examined; state limitations if applicable.)

• General/Hydration: [Appearance, distress, hydration status]
• Abdomen: [Distension, bowel sounds, tenderness with location, masses, organomegaly]
• Other pertinent systems: [Oropharynx, skin, perianal, joints, neuro as relevant]

Data Reviewed: [Pertinent labs, imaging, endoscopy/pathology, and outside records with dates] (Summarize key findings briefly; note independent interpretation if performed. Omit if no data reviewed.)

Assessment

(Numbered problem list in order of clinical priority. For each, include diagnosis or symptom-based diagnosis, status, and concise reasoning.)

1. [Problem 1]: [Working diagnosis] — [new / stable / worsening]. [Clinical reasoning in 1–3 sentences citing key supportive data and relevant differentials. For functional diagnoses, document evaluation or absence of red flags.]
2. [Problem 2]: [Diagnosis] — [new / stable / worsening]. [Brief reasoning.]
3. [Problem 3]: [Diagnosis] — [new / stable / worsening]. [Brief reasoning.]

Plan

(Organize by problem number. Include only applicable items for each problem.)

1. Problem 1:
   • [Diagnostics with rationale]
   • [Medications with dose, route, frequency, duration]
   • [Diet/nutrition interventions with targets; dietitian coordination if needed]
   • [Home monitoring instructions]
   • [Counseling points and shared decision-making]
   • [Return precautions with explicit red flags]
   • [Referrals/coordination]
   • [Follow-up timing and modality]
2. Problem 2:
   • [Actions as applicable]
3. Problem 3:
   • [Actions as applicable]

Total clinician time on date of service: [__] minutes (face-to-face and non-face-to-face). (Include only if time-based coding is used.)