Pediatric Nephrology Outpatient Progress Note (SOAP)

Date: [date of encounter]

Patient: [age, sex]

Visit Type: [new consultation / follow-up]

Chief Reason for Visit: [brief clinical label]

Subjective

[Interval history or presenting history] (Begin with the chief concern in the family's words if available, then translate to clinical terms. Attribute sources as per parent, per patient, or per outside records. Include relevant urinary symptoms, edema or volume symptoms, hypertension-related symptoms, intercurrent illnesses, and medication changes or adherence concerns. For hypertension visits, include home BP monitoring summary with device, frequency, and typical range. For hematuria or proteinuria visits, include timing patterns and relevant family history. For CKD surveillance, comment on growth, energy, and therapy adherence.)

Medications: [current medications with dose and frequency] (Include mg/kg/day for nephrology-relevant medications when available.)

Allergies: [allergies and reaction types]

PMH/FH/SH: [pertinent history] (For new visits, include prenatal findings if CAKUT suspected, prior nephrology workup, UTIs, nephrolithiasis, family history of CKD/ESRD/early hypertension/hearing loss, and targeted social history including sodium intake and activity. For follow-up visits, include updates only if relevant.)

Objective

Vitals: [temperature, heart rate, respiratory rate, SpO2 as available]

Growth: [height, weight, BMI with percentiles or z-scores] (If percentiles cannot be calculated, state this.)

Blood Pressure:

• [All clinic BP readings with technique] (Arm used, cuff appropriateness, seated/rested, repeat after rest if initially elevated.)
• [BP interpretation] (If age <13, provide percentile; if ≥13, use adult thresholds. Classify as normal, elevated, stage 1, or stage 2. If height missing, state percentiles cannot be calculated.)
• [Comparison to prior readings and home log summary] (State if home log not available. Include ABPM results if performed.)

Exam: [pertinent positives and negatives] (Include general appearance, hydration status, periorbital/peripheral edema, cardiovascular exam, abdominal exam, and skin findings as relevant to today's problems.)

Data: [relevant labs, urine studies, and imaging with dates and trends] (For labs, include creatinine/eGFR with equation used, electrolytes, albumin, CBC as relevant. For urine studies, specify specimen type first-morning vs random, dipstick findings, microscopy highlights, and protein quantification UPC or ACR with interpretation. For imaging, include modality, key findings, and comparison to prior. Note echocardiogram LVH status and ABPM interpretation if available. State explicitly if results are pending or unavailable.)

Assessment

(List problems in order of severity and clinical priority.)

[Problem 1]: [diagnosis or clinical impression]

Status: [improved / stable / worsening / unclear] — [brief supporting evidence from subjective and objective findings] (For hypertension: include stage, phenotype, and contributing factors. For hematuria: include gross vs microscopic and glomerular vs nonglomerular features. For proteinuria: include quantification and interpretation as transient, orthostatic, or persistent. For CKD: include etiology, stage, and trend. Include differential diagnosis if not yet established and risk statement if relevant.)

[Problem 2]: [diagnosis or clinical impression]

(Include additional problems only as needed, following the same format.)

Plan

(Organize by problem matching Assessment order.)

[Problem 1]

• [Diagnostics ordered with rationale]
• [Medication changes] (Include name, dose, route, frequency, mg/kg/day, and monitoring parameters.)
• [Lifestyle guidance] (Sodium intake, hydration, activity as applicable.)
• [Monitoring instructions] (Home BP schedule, urine collection timing, lab intervals.)
• [Referrals and care coordination] (Only if applicable.)
• [Return precautions] (Specify when to call: very high BP, gross hematuria, new edema, decreased urine output.)

[Problem 2]

(Include only if applicable, following the same format.)

Follow-up: [timeframe] — [what must be completed before next visit] — [in-person / telehealth]