Pediatrics Outpatient Progress Note (SOAP)

Date: [Date of service]

Patient: [Full name, DOB, age]

Visit Type: [acute / follow-up], [in-person / telehealth]

Clinician: [Clinician name, credentials]

Historian: [Relationship to patient; whether patient also contributed; if independent historian used, state who and why]

Interpreter: [Language, modality] (Omit line if not applicable)

Subjective

Chief Complaint: [Primary reason for encounter] (One concise line; list multiple concerns in priority order.)

HPI: [Brief narrative of current concern(s)] (Include onset, duration, severity, pertinent positives/negatives, exposures/sick contacts, home treatments tried and response. For chronic follow-ups, include interval symptom control and medication adherence. Document who observed symptoms when relevant to reliability.)

Relevant History: [Pertinent medical/surgical/family/birth history supporting today's visit] (Include only details directly relevant to today's problems.)

Allergies: [NKDA / specific allergen(s) and reactions / unknown—caregiver unsure] (Must be explicitly stated; never infer.)

Medications: [Medication list reviewed and updated: yes/no; current medications relevant to visit]

Objective

Vitals: [Temp with source, HR, RR, BP, SpO2 as obtained]; Weight: [kg] (required); [Height/Length, percentiles, BMI as clinically relevant]

Exam: [Pertinent positives and clinically meaningful negatives by system] (Use pediatric-appropriate descriptors: appearance, consolability, hydration, work of breathing. Include only systems meaningfully assessed. If exam was limited, briefly state why.)

Data: [Point-of-care results, relevant labs/imaging reviewed, external records with key findings] (Highlight abnormal or clinically significant values. Omit if no diagnostics obtained or reviewed.)

Assessment

(Numbered problem list in order of clinical priority. Include only problems actively addressed today.)

1. [Problem: Diagnosis or symptom, acuity/status] — [Concise synthesis of supporting findings; differential or uncertainty if applicable]
2. [Additional problems as applicable]

Plan

(Numbered to match Assessment problem order exactly. For each problem, include applicable elements: diagnostics ordered, medications with dose/route/frequency/duration, non-pharmacologic interventions, counseling provided, return precautions in parent-friendly language, follow-up timing, referrals. For weight-based dosing, include mg/kg basis and patient weight.)

1. [Plan elements for Problem 1]
2. [Plan elements for Problem 2, etc.]

Billing Support: [Total clinician time: __ minutes] or [MDM level supported by complexity of problems, data reviewed, and risk of management]

(If required information was not obtained, include brief explanation. Omit optional sections if not addressed. Do not infer immunization status, medication adherence, or allergies without explicit documentation.)