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Pediatric SOAP Note

Work with this pediatric SOAP note to document the child patient’s condition. Pediatricians can use this template to conduct the documentation of the child’s medical data. Provide proper diagnoses and present good therapy plans using this template or see how to write a SOAP note.

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Pediatric SOAP Note

Inspection

Subjective Data

Age:
Gender:
Main complaint:
History of Present Illness (location, quality, severity, timing, setting, alleviating/ aggravating factors, associated signs and symptoms):
Past Medical History (allergies, current medication, injuries, hospitalizations, surgeries):
Family medical history:
Social medical history:
Review of Systems:

Objective Data

Height (in):
Weight (lbs):
BMI:
General appearance:
Body temperature:
Eyes, Ears, Nose, Throat:
Blood pressure (BP):
Cardiovascular:
Respiratory:
Integument/ Lymphatic Inspection:
Laboratory Results:

Assessment

General Observations:
Differential Diagnosis:

Plan

Treatment/Therapy Plan:

Completion

Name and Signature of Pediatrician:
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Pediatrician Utilizes SOAP Note to Monitor Patient's Health Progress


A pediatric SOAP note is a type of progress form used by pediatricians, nurses, and other healthcare professionals when assessing the health of a child. It is based on the acronym SOAP, which stands for Subjective, Objective, Assessment, and Plan. The note includes information gathered from the patient and/or parent, physical exam findings, diagnoses, treatments, and a plan for future care. This pediatric SOAP note is used to document the patient's history and progress over time, and to communicate between members of the healthcare team. By having a detailed set of information, pediatric SOAP notes provide an organized approach to patient care.


Pediatric soap note template enables medical staff to provide clear and precise documentation of patient information. This way of recording helps those involved to get a precise overview and a better understanding of the patient's concerns and needs. This way standardized note formats like SOAP notes need to be adopted to avoid misunderstanding and ensure reliability in the patient's documentation process.


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