Pediatric Surgery SOAP Note

Date/Time: [Date and time of note]

Care Setting: [inpatient / outpatient]; [Location or service]

Author/Attending: [Author name and role] / [Attending physician]

Surgical Time-Course: [POD#, HD#, index procedure and date] (Include only for post-operative or established surgical patients; omit for new outpatient consults.)

Subjective

Chief concern / Interval events: [Patient/caregiver-stated concern or interval events since last evaluation] (Use meaningful verbatim wording when appropriate; for inpatient daily notes, begin with overnight events.)

Historian: [patient / parent-guardian / nursing / other] (Note reliability limitations such as age, developmental status, sedation, or communication barriers if present.)

Interval history: [Clinical trajectory; surgery-specific symptoms including pain, nausea/vomiting, wound concerns, fever; bowel function; diet/PO tolerance; functional recovery; caregiver concerns] (Include pertinent negatives only if they change management. Omit unchanged PMH/PSH/FH/SH unless directly relevant.)

Objective

Vitals/Weight: [Temp, HR, BP, RR, SpO2; weight in kg] (Note trends only if clinically meaningful; if not obtained, state reason.)

Lines/Tubes/Drains: [Inventory with status and necessity] (Include only for inpatient or post-op encounters with active devices; otherwise omit.)

Exam:

• [General appearance and comfort level]
• [Respiratory status]
• [Abdominal exam: distension, tenderness pattern, peritoneal signs]
• [Incision/wound assessment; drain sites if present]
• [Other systems as relevant to today's problem]

(Document only elements actually assessed.)

Data: [Key labs, imaging, pathology with brief interpretation] (Omit if no new data.)

Assessment

[One-sentence summary: age, key diagnosis, operative status, and current clinical trajectory]

1. [Problem name] — [improving / worsening / stable]; [brief supporting evidence] (Include differential only if diagnostic uncertainty exists.)
2. [Problem name] — [status]; [supporting evidence] (Include additional problems as needed.)

Plan

1. [Problem name]: [Diagnostics, therapeutics, and monitoring as relevant to this problem] (For problems involving operative decision-making: document indication, alternatives considered, risks/benefits discussed, urgency/timing, shared decision-making participants including parent/guardian and patient assent if applicable, and consent status.)
2. [Problem name]: [Plan elements relevant to this problem]

Disposition: [Discharge criteria or anticipated timing for inpatients; follow-up location and timeframe for all encounters]

Electronic Signature: [Name, credentials, role]

Attending Attestation: [Attestation statement and signature] (Include if trainee note; otherwise omit.)