Pediatric SOAP Notes (with Examples & Template)

As a pediatrician, you see children of all ages, from newborns to teenagers, and every visit can be very different. One thing, however, should always stay the same: clear and structured documentation. Pediatric SOAP notes provide a simple, organized way to capture your thoughts, remember key details, and communicate effectively with parents and the healthcare team. When written well, they save time, support better clinical decisions, and protect you medicolegally.

In this guide, we will walk through what pediatric SOAP notes are, why they matter, and how to write them step by step, with examples.

What are Pediatric SOAP Notes?

A SOAP note is a structured way to write clinical notes. SOAP is an acronym that stands for: S – Subjective, O – Objective, A – Assessment, and P – Plan. Pediatric SOAP notes follow the same structure as adult ones, but the content is different because children often cannot express themselves clearly. You get much of the story from parents, caregivers, or other adults (teachers, school nurse, etc.), and you must adjust your questions based on the child’s age and development.

The main goals of pediatric SOAP notes are to:

• Capture the child’s symptoms and parent concerns in an organized way
• Record relevant growth and development facts
• Document your clinical findings and reasoning
• Create a clear plan for treatment and follow-up

Why SOAP Notes Are Important in Pediatrics

SOAP notes are especially important in pediatrics because children often cannot explain their symptoms clearly. Infants and young children rely completely on parents and caregivers to describe what is happening, which means information can be emotional, incomplete, or unclear. A structured SOAP format helps the pediatrician take all pieces of information, parent observations, child behavior, and clinical findings, and organize them in a way that makes medical decision-making accurate and logical. Clear documentation also allows the provider to track changes over time, such as growth patterns, developmental milestones, or repeated illnesses, which are essential parts of pediatric care.

Another reason SOAP format matter in pediatrics is that children’s conditions can change quickly. A child who seems stable in the morning may worsen by evening, so having detailed notes supports safe follow-up and reduces the risk of missed warning signs. Well-written notes also improve communication among the healthcare team. Pediatric care often involves multiple providers, pediatricians, nurses, ENT specialists, pulmonologists, school health staff, and therapists. When each visit is documented clearly, the next provider knows exactly what was found, what was discussed, and what the plan was. This prevents repetition, confusion, and medical errors.

SOAP notes also strengthen communication with parents. Families often feel anxious or overwhelmed when their child is sick, and clear documentation ensures consistency in what they are told at each visit. Detailed notes show what instructions were given, what red-flag symptoms to watch for, and when to return. This protects the child and also provides medicolegal protection for the pediatrician by showing the reasoning behind clinical decisions. In pediatric medicine, where safety and clarity are essential, strong SOAP notes are a key part of delivering high-quality, reliable care.

S – Subjective in Pediatric SOAP Notes

The Subjective part is what you hear, not what you see. It is the “story” section.

In pediatrics, this usually comes from:

• Parents or caregivers
• The child (depending on age and development)
• Sometimes other sources: school, daycare, previous notes, discharge summaries

Key parts of the Subjective section

You can structure the Subjective part like this:

1. Chief Complaint (CC)
   • One short sentence in the parent’s or child’s own words.
   • Example:
     • “Fever and cough for 2 days.”
     • “Stomach pain since last night.”
     • “He has been more sleepy and not eating.”
2. History of Present Illness (HPI)This is a more detailed story of the problem. For pediatrics, think: OLD CARTS or OPQRST (onset, location, duration, etc.), but use simple explanations. Include:
   • Onset: When did it start?
   • Duration: How long has it been going on?
   • Timing: Constant or comes and goes?
   • Location: Where is the pain or problem?
   • Character: Type of symptom (sharp, dull, dry cough, wet cough, etc.)
   • Associated symptoms: Fever, vomiting, rash, poor feeding, irritability, etc.
   • Relieving/worsening factors: What makes it better or worse?
   • Previous episodes: Has this happened before?
   • Treatments tried: Any medicines, home remedies, or previous visits?
   Example (HPI):“Mother reports 4-year-old boy with cough and fever for 2 days. Fever up to 38.9°C, measured at home. Cough is worse at night and sounds ‘wet’. The child has less appetite but is drinking water. No vomiting, no diarrhea. There is mild nasal congestion. No known sick contacts except older sister, who had a ‘cold’ last week. Mother gave paracetamol with some relief of fever.”
3. Past Medical History (PMH)
   • Birth history (important in infants and younger children): gestational age, delivery type, complications.
   • Chronic conditions (asthma, congenital heart disease, epilepsy, diabetes, ADHD, etc.).
   • Previous hospitalizations and surgeries.
   • Allergies, especially drug and food allergies.
   • Immunization status (up to date, missing vaccines, unknown).
4. Medications
   • Regular medications (daily asthma inhaler, ADHD medication, etc.)
   • As-needed medications (bronchodilators, paracetamol, ibuprofen).
   • Recent antibiotics or steroids.
5. Family History (FH)
   • Important conditions: asthma, allergies, diabetes, hypertension, epilepsy, mental health issues, and genetic conditions.
   • Who in the family is affected (mother, father, siblings, grandparents)?
6. Social History (SH)Pediatric social history is very important. Include:
   • Who lives at home with the child
   • School/daycare attendance
   • Smoking exposure (inside house or car)
   • Pets at Home
   • Recent travel
   • Safety concerns, if any (car seat use, helmet, etc.)
7. Developmental History (for infants and young children)
   • Gross motor, fine motor, language, and social skills
   • Any delays or concerns reported by parents or teachers
8. Review of Systems (ROS)This is a checklist of symptoms by body system. In pediatrics, keep it focused and age-appropriate:
   • General: fever, weight loss, fatigue
   • ENT: runny nose, ear pain, sore throat
   • Respiratory: cough, wheezing, shortness of breath
   • GI: vomiting, diarrhea, constipation, abdominal pain
   • GU: urinary frequency, pain with urination, bedwetting
   • Skin: rash, itching
   • Neuro: headaches, seizures, behavior changes

Write this section in clear sentences, avoiding too many abbreviations. Always note who is giving the history (e.g., “History obtained from mother”).

O – Objective in Pediatric SOAP Notes

The Objective section is what you see, measure, and observe during the visit.

Vital signs

Always include:

• Temperature
• Heart rate
• Respiratory rate
• Blood pressure (if appropriate for age)
• Oxygen saturation
• Weight
• Height/length
• Head circumference (for infants and young toddlers)

Whenever possible, compare weight and height to growth charts or percentiles and note them. If the child is underweight or overweight, mention this clearly.

Physical exam

Consistently structure the exam, such as:

• General appearance
  • Alert, active, playful, crying but consolable, lethargic, in acute distress, etc.
• Head, Eyes, Ears, Nose, Throat (HEENT)
  • Head shape, fontanelles in infants
  • Eyes: redness, discharge, pupil reaction
  • Ears: tympanic membrane color, position, mobility
  • Nose: congestion, discharge
  • Throat: redness, tonsillar swelling, exudates
• Neck
  • Lymph nodes, stiffness, swelling
• Chest/Lungs
  • Respiratory effort (retractions, nasal flaring)
  • Breath sounds: clear, wheeze, crackles, diminished
• Cardiovascular
  • Heart sounds, murmurs, rhythm
  • Capillary refill, pulses
• Abdomen
  • Shape, tenderness, guarding, masses
  • Bowel sounds
• Skin
  • Rashes, bruising, pallor, cyanosis, and dehydration signs
• Neurological
  • Level of consciousness, muscle tone, reflexes (age-dependent)
  • For infants: primitive reflexes (Moro, rooting, grasp) if needed
• Musculoskeletal
  • Gait (for walkers), limb movement, joint swelling, deformity

Document only what you actually did and saw. If certain parts were not examined, you can write “Not examined” instead of guessing.

Tests and investigations

Include any point-of-care tests or investigations done during the visit:

• Rapid strep test, rapid flu test, COVID test
• Blood glucose
• Urinalysis
• Imaging (X-ray, ultrasound, etc.)
• Lab tests (CBC, CRP, cultures, etc.)

Write the results briefly but clearly, including normal and abnormal findings.

A – Assessment in Pediatric SOAP Notes

The Assessment is your clinical judgment based on the Subjective and Objective information.

It usually includes:

1. Primary diagnosis (working diagnosis)
2. Secondary diagnoses (chronic conditions, co-existing problems)
3. Sometimes, a differential diagnosis list, especially for unclear or complex cases

Writing good pediatric assessments

• Use age-appropriate diagnosis (e.g., “viral upper respiratory infection,” “acute otitis media,” “mild intermittent asthma”).
• Reflect the severity (mild, moderate, severe; controlled vs uncontrolled).
• Note important risk factors (e.g., “recurrent wheeze in child with family history of asthma”).

Example Assessment:

1. Acute viral upper respiratory infection in a 4-year-old boy, stable, no signs of respiratory distress.
2. History of mild intermittent asthma, currently well controlled.
3. Overweight (BMI at 95th percentile) – needs further counseling and follow-up.

If you are not fully sure of the diagnosis, you can say “likely” or “possible,” and mention your top differentials.

P – Plan in Pediatric SOAP Notes

The Plan is what you will do now and next. It should be specific, clear, and practical, and it should address both the child and the caregiver.

You can break the Plan into parts:

1. Diagnostics / Tests
   • Any new labs or imaging you will order
   • Example: “Order CXR if worsening cough or breathing difficulty in the next 24–48 hours.”
2. Medications and treatments
   • Name of medicine
   • Dose (mg/kg if weight-based), route, frequency, and duration
   • Clear instructions (with or without food, max daily dose, emergency use)
   • Example: “Paracetamol 15 mg/kg orally every 6 hours as needed for fever, maximum 4 doses in 24 hours.”
3. Non-pharmacologic care
   • Fluids, rest, saline nasal drops, humidifier, diet advice, skin care, etc.
4. Parent/caregiver education
   • Explain the disease in simple words
   • Tell them what to expect: “Cough may last 1–2 weeks.”
   • Red-flag signs: when to go to ER or call urgently (e.g., breathing fast, chest pulling in, bluish lips, not drinking, no urine, very sleepy).
   • Demonstrate inhaler technique or other devices when needed.
5. Follow-up
   • When to come back (specific time frame: 24 hours, 2 days, 1 week, etc.)
   • Whether follow-up can be in-person or via telehealth.
6. Referrals
   • To specialists (allergist, ENT, neurologist, developmental pediatrician, psychologist, etc.)
   • To services (speech therapy, occupational therapy, dietitian).

Example Plan

1. Supportive care for viral URI: encourage oral fluids, saline nasal drops, head elevation during sleep.
2. Paracetamol 15 mg/kg orally every 6 hours as needed for fever, max 4 doses per day. Avoid ibuprofen if poor oral intake.
3. Educated mother about signs of respiratory distress: fast breathing, chest retractions, noisy breathing, difficulty talking, or bluish lips. If any of these occur, go to emergency immediately.
4. Follow-up in 2 days or sooner if symptoms worsen.
5. Continue daily asthma controller inhaler as prescribed. Check inhaler technique at next visit.

Age-Specific Tips for Pediatric SOAP Notes

Here are some age-specific tips for writing pediatric SOAP notes to help you adapt your documentation to each stage of childhood.

Infants (0–12 months)

For infants (0–12 months), most of the story comes from parents, so you focus on feeding habits, sleep patterns, crying behavior, diaper output, growth, and early developmental milestones. The objective exam includes weight, length, head circumference, fontanelle status, muscle tone, and primitive reflexes.

Assessments often involve feeding difficulties, reflux, colic, infections, jaundice, or growth concerns. Your plan should use simple, clear language for parents, explaining what is normal, what is not, and giving strong safety and follow-up instructions so they know exactly when to return.

Toddlers and Preschoolers (1–5 years)

For toddlers and preschoolers (1–5 years), parents still describe most symptoms, but the child can point or use simple words to show what hurts. You should explore behavior changes, appetite, sleep, and play levels. In the objective exam, examine the ears, throat, and lungs carefully, and observe how the child plays or interacts. Common assessments include frequent infections, minor injuries, wheezing or asthma, allergies, and developmental concerns. Your plan should include simple educational tools, like drawings or props, and give advice on hygiene, nutrition, and injury prevention to support the family at home.

School-Age (6–12 years)

For school-age children (6–12 years), the child can express their pain and feelings more clearly, so include both the child’s and the parent’s perspective. Ask about school performance, attention, bullying, friendships, and mood. The objective exam may include vision screening, posture, musculoskeletal checks, and signs of early puberty.

Assessments in this group are often related to asthma, allergies, obesity, ADHD, learning issues, or headaches. The plan should encourage healthy habits like physical activity, good sleep routines, and limited screen time, while involving the child in decisions so they feel confident and responsible.

Adolescents (13–18 years)

For adolescents (13–18 years), privacy and trust are essential. Spend a few minutes alone with the teen if possible and ask about mood, friends, school stress, social media use, substance exposure, and sexual health in a calm, respectful way. Objective findings include growth, puberty stage, acne, and mental status. Assessments may include depression, anxiety, eating disorders, or risky behaviors. The plan should promote honest communication, encourage independence, and involve parents only when needed or appropriate. Always document discussions about confidentiality to support safe and ethical care.

Tips for Writing Better Pediatric SOAP Notes

Writing good pediatric SOAP notes takes practice, but small improvements can make a big difference in the clarity and safety of your documentation. Children cannot always explain their symptoms, so your notes must be clear, to the point and easy for any clinician to understand later. These tips will help you stay organized, support better clinical judgment, and make your notes more useful for both healthcare teams and families.

Use Simple and Clear Language

Using simple and clear language reduces confusion, even when the note is mainly for other professionals. When you write straightforwardly, it becomes easier for anyone reading the note to understand your findings quickly. This is especially helpful during follow-up visits, emergencies, or when another clinician continues care.

Avoid long, complex sentences or advanced medical terms when a simpler phrase works just as well. Clear wording helps maintain accuracy and prevents misinterpretation, especially in pediatric cases where small details matter.

Be Specific, Not Vague

Vague descriptions can make your note unclear and limit its usefulness. Phrases like “doing well” or “the child is stable” do not show the true clinical picture. Instead, be specific and describe what you observed, for example: “afebrile, eating normally, playful, and no breathing difficulty.” This level of detail supports better decision-making and makes the child’s progress easier to track over time. Specific notes also improve communication between providers and help parents understand the child’s condition when they receive explanations based on your documentation.

Document Caregiver Concerns Clearly

Parents and caregivers often notice important changes long before a clinician does, so their concerns should be recorded clearly. Their observations—such as reduced appetite, unusual crying, sleep changes, or behavior differences—can help identify early signs of illness. Documenting caregiver concerns also shows respect for their role and strengthens trust. Writing these concerns in a clear, organized way helps ensure that you address all their questions and do not overlook key details during assessment and planning.

Include Growth and Development Regularly

Growth and development are central parts of pediatric care. Notes that include weight, height, percentiles, and milestones help track whether a child is developing as expected. These details allow you to notice patterns, detect early delays, and support long-term care planning.

Including developmental comments, such as language skills, motor skills, or social interaction, helps create a full picture of the child’s overall well-being. Pediatric care is not only about treating disease; it is also about monitoring healthy progress, and your notes should reflect that.

Use Templates or Checklists

Templates and checklists can greatly improve the consistency and completeness of your SOAP notes. When you follow a structured format, you are less likely to forget important items such as vital signs, developmental milestones, or parent concerns. This is especially useful during busy clinic days when it is easy to overlook small but important details. Age-specific checklists are particularly helpful in pediatrics because infants, toddlers, school-aged children, and teens all require different types of information. Using standardized tools also ensures that all providers in a clinic follow the same high level of documentation.

Record Education and Safety Advice

Caregiver education is a major part of pediatric practice. It is important to document what you explained about medications, dosages, home care, and safety instructions. Recording red-flag symptoms, such as difficulty breathing, dehydration signs, or worsening pain, helps protect the child and keeps communication clear.

Writing down this guidance also provides a record for future visits, showing what was taught and whether the parent understood. This helps avoid confusion and creates a consistent care plan across multiple appointments or providers.

Protect Confidentiality, Especially for Teens

Adolescents often share sensitive personal information about mental health, substance use, relationships, or school stress. It is important to protect their privacy and follow local laws and clinic policies when documenting these details. Respecting confidentiality helps teens feel safe and supported during their care.

Your note should include only what is necessary for clinical decision-making, not every detail the teen shares. Clear but careful documentation helps maintain trust while also ensuring safety, especially when discussing issues that could affect their health or well-being.

Common Mistakes in Pediatric SOAP Notes (and How to Avoid Them)

Writing clear and complete pediatric SOAP notes is essential for safe and effective care, but many clinicians unintentionally make small mistakes that weaken the documentation. These errors often happen during busy clinic days or when caring for young children who cannot fully explain their symptoms. By becoming aware of these common problems, you can improve your note quality, support better decision-making, and ensure continuity of care for every child. Below are the most frequent mistakes and simple ways to prevent them.

Missing Basic Data

One of the most common mistakes in pediatric SOAP notes is leaving out essential information such as weight, vital signs, and growth percentiles. These details are critical because even small changes can indicate illness, dehydration, or growth concerns. Missing this data makes it hard to track the child’s progress or understand the severity of the condition.

How to avoid it: Always begin the Objective section with a standard checklist. Include temperature, heart rate, respiratory rate, oxygen saturation, weight, height, and appropriate growth percentiles. A fixed template keeps your documentation complete and consistent.

Vague Descriptions

Another frequent problem is using unclear or general statements such as “child is fine” or “the lungs are okay.” These vague descriptions do not tell other clinicians what you actually observed and offer no meaningful clinical value.

Clear, descriptive language makes your findings useful and helps guide accurate decisions. It also strengthens the medical record if another provider or parent reviews it later.

How to avoid it: Use specific and objective wording like:

“Lungs clear to auscultation, no wheezes or crackles, no retractions.”

Not Specifying Medication Doses

A common and potentially dangerous mistake is writing medication instructions without including doses or frequency. For example, “Give paracetamol” is not enough information for safe pediatric care. Since pediatric doses depend on weight, exact instructions are essential.

How to avoid it: Always include mg/kg dose, route (oral, inhaled, etc.), frequency, and duration. Clear instructions protect the child and reduce the risk of dosing errors.

Poor Documentation of Parent Education

Caregiver education is a vital part of pediatric care, but many notes fail to document what was explained. If you don’t write it, it may appear as if the education never happened. This becomes important during follow-ups or if the child’s condition worsens.

How to avoid it: Add a simple line such as:

“Discussed diagnosis, home care, and warning signs with mother; she verbalized understanding.”
This shows that you provided guidance and confirmed comprehension.

Pediatric SOAP Notes Template and Examples

Below are practical and easy-to-understand pediatric SOAP note examples that show how to document real clinical situations clearly and professionally. Each example follows the SOAP format used in everyday pediatric care.

Final Thoughts

Pediatric SOAP notes are not just a form you “have to fill.” They are a tool that helps you think clearly, communicate with families, and give safe and effective care to children. When you consistently use a clear structure for Subjective, Objective, Assessment, and Plan, you:

• Reduce errors
• Save time on future visits
• Improve continuity of care
• Support better outcomes for your young patients

By writing perfect pediatric SOAP notes, you create a trustworthy record that shows your clinical reasoning and your care for both the child and the family.