Pediatrics: Step-by-Step Guide on How to Write SOAP Notes

Updated January 2026

Pediatric SOAP notes require special considerations that differ significantly from adult documentation. Children's developmental stages, inability to self-report symptoms, and the critical role of caregivers all impact how notes should be structured. This guide provides detailed instructions for documenting pediatric encounters across all age groups, from newborns to adolescents.

Unique Aspects of Pediatric Documentation

Pediatric documentation differs from adult notes in several key ways:

1. Developmental Context: Always document within the context of the child's developmental stage
2. Caregiver Involvement: Much of the subjective information comes from parents/caregivers
3. Growth Monitoring: Height, weight, and head circumference percentiles are essential
4. Age-Specific Norms: Vital signs and exam findings must be interpreted by age
5. Anticipatory Guidance: Well-child visits include significant patient education components
6. Immunization Tracking: Vaccine administration and schedules are integral

Subjective Section (S)

In a pediatric SOAP note, the Subjective section captures information from the child (when age-appropriate) and from parents or caregivers. This dual-source approach is essential for comprehensive documentation.

Subjective Section (S) Components

1. Chief Complaint:

   • The primary reason for the visit, noting the source of information
   • Example: "Mother reports child has had fever and ear pain for 2 days"

2. History of Present Illness:

   • Detailed description with timeline
   • Impact on eating, sleeping, activity level, and behavior
   • Example: "3-year-old male with 2-day history of fever (max 102.4°F), pulling at right ear, decreased appetite, and irritability. No vomiting or diarrhea. Sleeping poorly due to discomfort."

3. Review of Systems (Age-Appropriate):

   • Feeding/appetite changes
   • Sleep patterns
   • Urine output/wet diapers
   • Bowel movements
   • Activity level and behavior changes
   • Example: "Decreased appetite, only drinking fluids. Normal wet diapers. No rash, no cough, no rhinorrhea."

4. Past Medical History:

   • Birth history (gestational age, birth weight, complications)
   • Previous hospitalizations or surgeries
   • Chronic conditions
   • Example: "Term delivery, birth weight 7 lbs 4 oz, uncomplicated. No hospitalizations. History of eczema."

5. Developmental History:

   • Milestones achieved
   • Any developmental concerns
   • School performance (if applicable)
   • Example: "Meeting all developmental milestones. Speaks in 3-4 word sentences, runs, climbs stairs."

6. Immunization Status:

   • Current with schedule or specific vaccines needed
   • Example: "Immunizations up to date per CDC schedule through 2-year visit."

7. Medications and Allergies:

   • Current medications including OTC and supplements
   • Allergies with reaction type
   • Example: "No daily medications. Allergic to amoxicillin (rash)."

8. Family History:

   • Relevant genetic or familial conditions
   • Example: "Family history of asthma (mother), no history of hearing loss."

9. Social History:

   • Living situation, caregivers
   • Daycare/school attendance
   • Secondhand smoke exposure
   • Example: "Lives with both parents, attends daycare 5 days/week. No smoke exposure."

Example Subjective Section for Pediatrics

Objective Section (O)

The Objective section in pediatrics must include age-specific vital sign interpretation and developmentally appropriate examination techniques.

Objective Section (O) Components

1. Vital Signs with Percentiles:

   • Temperature, heart rate, respiratory rate, blood pressure (if indicated)
   • Weight, height/length, and head circumference with percentiles
   • BMI percentile for children ≥2 years
   • Example: "Weight: 14.5 kg (50th percentile), Height: 95 cm (45th percentile), BMI: 16.1 (55th percentile)"

2. General Appearance:

   • Activity level, interaction, consolability
   • Nutritional status
   • Example: "Alert, interactive, mildly fussy but consolable. Well-nourished, well-hydrated."

3. Age-Appropriate Physical Examination:

   • Systematic examination adapted for age
   • Document child's cooperation level
   • Example: "Child cooperative for examination, sitting in mother's lap."

4. Developmental Assessment:

   • Observations relevant to developmental milestones
   • Screening tool results if administered
   • Example: "Appropriate stranger awareness, uses 3-word phrases, follows simple commands."

5. Growth Chart Documentation:

   • Reference to growth trajectory
   • Any concerning trends
   • Example: "Growth tracking along 50th percentile for weight, consistent with previous visits."

Pediatric Vital Signs Reference

Example Objective Section for Pediatrics

Assessment Section (A)

The Assessment synthesizes findings with attention to age-specific differential diagnoses and developmental context.

Assessment Section (A) Components

1. Diagnosis with ICD-10 Code:

   • Primary and secondary diagnoses
   • Specify laterality when applicable
   • Example: "Acute otitis media, right ear (H66.91)"

2. Clinical Reasoning:

   • Why this diagnosis fits the clinical picture
   • Ruled-out differentials
   • Example: "Bulging, erythematous TM with effusion and decreased mobility consistent with AOM. No signs of mastoiditis or complicated infection."

3. Growth and Development Assessment:

   • Growth trajectory evaluation
   • Developmental status
   • Example: "Growth following established curve at 50th percentile. Development appropriate for age."

4. Severity Assessment:

   • Mild, moderate, or severe classification when applicable
   • Example: "Moderate severity AOM based on moderate symptoms and unilateral involvement."

Example Assessment Section for Pediatrics

Plan Section (P)

The Plan must include age-appropriate medication dosing, caregiver education, and appropriate follow-up.

Plan Section (P) Components

1. Medications:

   • Weight-based dosing clearly documented
   • Age-appropriate formulations
   • Example: "Cefdinir 14 mg/kg/day divided BID x 10 days = 7 mL (125mg/5mL) twice daily"

2. Antipyretics/Symptom Management:

   • Clear weight-based dosing for OTC medications
   • Example: "Acetaminophen 15 mg/kg (220 mg) every 4-6 hours PRN fever/pain"

3. Return Precautions:

   • Age-specific warning signs
   • When to seek immediate care
   • Example: "Return if fever persists >48-72 hours on antibiotics, increased irritability, lethargy, or refusal to drink."

4. Anticipatory Guidance:

   • Age-appropriate safety and developmental guidance
   • Example: "Discussed car seat safety, pool safety for summer."

5. Follow-Up:

   • Specific timing and purpose
   • Example: "Follow-up in 10-14 days for ear recheck, or sooner if symptoms worsen."

6. Immunizations:

   • Vaccines given or scheduled
   • Example: "Due for flu vaccine - administered today."

Example Plan Section for Pediatrics

Well-Child Visit Documentation

Well-child visits require comprehensive documentation including developmental screening, anticipatory guidance, and preventive care.

Well-Child Visit Components

AI-Assisted Documentation for Pediatrics

AI scribes and ambient clinical intelligence are increasingly used in pediatric settings. According to AMA research, 66% of healthcare providers now use AI tools in practice.

Pediatrics-Specific AI Considerations

What AI captures well:

• History from parent/caregiver conversations
• Review of systems discussions
• Anticipatory guidance provided
• Follow-up instructions

What requires careful review:

• Growth percentiles and trends (verify calculations)
• Weight-based medication dosing (critical to verify)
• Developmental milestone documentation
• Immunization records
• Age-specific vital sign interpretation
• Which family member provided history

Tips for AI Documentation in Pediatrics

1. Clarify information source: "Mom reports..." vs. "Child states..."
2. Verbalize growth data: "Weight is 14.5 kilograms, which is 50th percentile"
3. State dosing clearly: "Prescribing amoxicillin 90 milligrams per kilogram per day"
4. Document developmental observations: "I'm observing that the child is speaking in 3-word sentences"

For more details, see our AI-Assisted Documentation Guide.

Telehealth Pediatrics Documentation

Telehealth has expanded access to pediatric care, particularly for behavioral health, chronic disease management, and minor acute complaints. Per CMS 2026 guidelines, specific documentation requirements apply.

Telehealth-Specific Pediatric Documentation

When In-Person Pediatric Visit is Needed

Document recommendation for in-person care when:

• Physical examination is essential for diagnosis
• Growth parameters need verification
• Immunizations are due
• Developmental screening requires standardized assessment
• Severity of illness is uncertain
• Parent/caregiver has difficulty assessing child remotely

For complete telehealth documentation guidance, see our Telehealth SOAP Notes Guide.

Free Pediatrics SOAP Note Template

Related Resources

• Telehealth SOAP Notes Guide
• AI-Assisted Documentation Guide
• Nurse Practitioner SOAP Notes