SOAP Note Example
Pediatric SOAP Note Example
Below is a complete SOAP note example for a 4-year-old well-child visit including developmental screening, growth assessment, immunization review, and anticipatory guidance. This example demonstrates proper documentation of caregiver-reported history, age-appropriate exam findings, and pediatric-specific treatment planning.
Complete Pediatrics Note
SUBJECTIVE:
Patient is a 4-year-old male presenting for a well-child visit accompanied by his mother. Mother reports no acute concerns today — states he is "doing great" and "keeping up with the other kids at preschool." Mother reports he is enrolled in a half-day preschool program 5 days per week and transitioned smoothly at the start of the school year. Developmental history per caregiver report: speech — speaking in full sentences of 5-6 words, able to tell simple stories about his day, asks "why" questions frequently, and is understood by strangers approximately 90% of the time. Fine motor — can draw a circle and a cross, attempts to draw a person with 3-4 body parts, uses scissors with supervision, and buttons large buttons independently. Gross motor — runs smoothly, hops on one foot 3-4 times, pedals a tricycle, and can catch a large ball with both hands. Social-emotional — plays cooperatively with peers at preschool, takes turns with prompting, engages in pretend play with elaborate scenarios, and separates from mother without significant distress at school drop-off. Mother reports occasional difficulty with emotional regulation — "he has big meltdowns when he doesn't get his way, maybe 2-3 times a week" — lasting approximately 5-10 minutes, responsive to redirection. Toileting: fully daytime potty-trained for 8 months, occasional nighttime wetting 1-2 times per week, wears pull-up at night. Diet: mother describes him as a "picky eater" — prefers chicken nuggets, pasta, and fruit; refuses most vegetables; drinks approximately 16-20 oz whole milk daily and water throughout the day; no juice. Sleep: sleeps approximately 10-11 hours per night with a consistent bedtime routine at 7:30 PM, no longer naps. No screen time before bed; approximately 1 hour of tablet use daily, supervised. Denies recent illnesses, injuries, emergency department visits, or hospitalizations since the last well-child visit at age 3. No current medications. Allergies: no known drug or food allergies. Family history: maternal grandmother with Type 2 diabetes, father with seasonal allergies and mild asthma. No family history of developmental delays, autism spectrum disorder, hearing loss, or vision problems. Patient lives at home with both parents and a 7-month-old sibling. Home environment: no tobacco smoke exposure, firearms secured with trigger locks in a locked safe per father's report at the prior visit, home has working smoke and carbon monoxide detectors.
OBJECTIVE:
Vital signs: weight 37.2 lbs (16.9 kg) — 55th percentile, height 40.5 inches (102.9 cm) — 52nd percentile, BMI 15.8 — 58th percentile (healthy weight), blood pressure 96/58 mmHg (appropriate for age, sex, and height percentile), heart rate 98 bpm, respiratory rate 22 breaths per minute, temperature 98.6 degrees Fahrenheit tympanic. Growth trend: weight and height tracking consistently between the 50th and 60th percentiles since age 2, no crossing of percentile lines, BMI stable in the healthy range. Vision screening: passed bilateral Lea symbols screening at 20/40 (age-appropriate threshold). Hearing screening: passed bilateral pure-tone audiometry at 1000, 2000, and 4000 Hz at 20 dB. Developmental screening: Ages and Stages Questionnaire, Third Edition (ASQ-3) completed by mother — Communication 55 (cutoff 26.2, above threshold), Gross Motor 54 (cutoff 32.6, above threshold), Fine Motor 42 (cutoff 25.1, above threshold), Problem Solving 50 (cutoff 27.5, above threshold), Personal-Social 50 (cutoff 29.4, above threshold). All domains well above cutoff — no concerns identified. Modified Checklist for Autism in Toddlers, Revised (M-CHAT-R/F) — not administered; screening completed at the 18-month and 24-month visits per AAP schedule, results were negative at both time points. Physical examination: General — well-nourished, well-developed, alert, active, playful, cooperative with exam after initial shyness. HEENT — head normocephalic and atraumatic; anterior fontanelle fully closed; eyes — pupils equal, round, reactive to light; no strabismus on cover-uncover test; red reflex present bilaterally; ears — tympanic membranes pearly gray bilaterally with visible landmarks and normal light reflex, no effusion; nose — patent bilaterally, no discharge; oropharynx — moist mucous membranes, 20 primary teeth present and in good condition, no dental caries visible, no tonsillar enlargement. Neck — supple, no lymphadenopathy, thyroid midline and non-enlarged. Cardiovascular — regular rate and rhythm, no murmurs, S1 and S2 normal, femoral pulses 2+ bilaterally. Respiratory — lungs clear to auscultation bilaterally, no wheezing, crackles, or stridor, symmetric chest expansion. Abdomen — soft, non-tender, non-distended, no hepatosplenomegaly, no masses, normoactive bowel sounds. Genitourinary — male, Tanner stage I, testes descended bilaterally, no inguinal hernia. Musculoskeletal — full range of motion in all extremities, normal gait and posture, spine straight without scoliosis, no limb length discrepancy. Skin — no rashes, birthmarks unchanged from prior documentation (single 1 cm café-au-lait macule on left flank, stable), no bruising in unusual locations. Neurological — cranial nerves grossly intact, normal muscle tone and strength symmetrically, deep tendon reflexes 2+ bilaterally at biceps and patellar. Immunization review: up to date through age 3 per state immunization registry. Due today per CDC/AAP schedule: DTaP (5th dose), IPV (4th dose), MMR (2nd dose), varicella (2nd dose), influenza (annual, seasonal). Mother consents to all immunizations. Vaccines administered this visit: DTaP (Daptacel, lot #AC14B098, exp 09/2026, right deltoid, 0.5 mL IM), IPV (IPOL, lot #N4537, exp 07/2026, left deltoid, 0.5 mL IM subcutaneous), MMR (M-M-R II, lot #L032479, exp 11/2026, right anterolateral thigh, 0.5 mL subcutaneous), varicella (Varivax, lot #K009831, exp 08/2026, left anterolateral thigh, 0.5 mL subcutaneous), influenza quadrivalent (Fluzone, lot #UJ789, exp 06/2026, left deltoid, 0.5 mL IM). Vaccine Information Statements (VIS) provided to mother for each vaccine prior to administration; mother verbalized understanding and signed consent forms. Patient monitored for 15 minutes post-vaccination — no adverse reactions observed.
ASSESSMENT:
Patient is a healthy 4-year-old male presenting for a well-child visit with age-appropriate growth, development, and physical examination findings. Growth parameters remain stable and proportionate between the 50th and 60th percentiles with a healthy BMI. All ASQ-3 developmental domains score well above cutoff thresholds, indicating development is on track across communication, motor, problem-solving, and personal-social skills. The caregiver-reported tantrums at 2-3 episodes per week lasting 5-10 minutes and responsive to redirection are within the range of typical emotional development for a 4-year-old and do not suggest a behavioral disorder at this time. Nighttime enuresis 1-2 times per week is developmentally normal — nocturnal bladder control is not expected to be fully established until age 5-7, and no intervention is warranted at this time. Picky eating is age-appropriate but warrants monitoring — current milk intake of 16-20 oz daily is within the recommended range (no more than 24 oz) and is not displacing solid food intake based on adequate growth parameters. Vision and hearing screening results are within normal limits. Physical examination is unremarkable with no new findings. Single café-au-lait macule remains stable and isolated — no features suggestive of neurofibromatosis. Immunizations brought up to date per the CDC/AAP recommended schedule. No safety concerns identified based on home environment review.
PLAN:
Anticipatory guidance provided to mother: nutrition — continue to offer a variety of foods including vegetables alongside preferred foods without pressure, involve the child in food preparation as a strategy to increase willingness to try new foods, transition from whole milk to low-fat or skim milk now that the child is over age 2, limit milk to 16 oz daily to avoid iron deficiency, and ensure adequate calcium intake (1000 mg per day target); safety — reinforce car seat guidelines (forward-facing car seat with harness until at least 40 lbs or per manufacturer limits, then booster seat), reinforce helmet use for tricycle riding, review water safety and direct adult supervision around any body of water, discuss pedestrian safety as the child is becoming more independent outdoors; dental — schedule dental visit every 6 months if not already established, brush teeth twice daily with a pea-sized amount of fluoride toothpaste with parental assistance; behavior — validate that tantrums at this age are developmentally expected and review positive discipline strategies including giving clear choices, naming emotions for the child, and maintaining consistent boundaries; nighttime wetting — reassure that this is normal for age and does not require treatment, continue pull-ups at night, avoid fluid restriction or punishment; physical activity — encourage at least 60 minutes of active play daily, limit screen time to 1 hour per day of high-quality programming per AAP guidelines. Next well-child visit scheduled at age 5, which will include a comprehensive kindergarten readiness assessment, vision screening per updated protocol, hearing screening, and any catch-up immunizations if needed. Mother to call the office if she observes regression in any developmental milestones, new or worsening behavioral concerns, prolonged fevers following today's vaccinations (greater than 48 hours or temperature above 104 degrees Fahrenheit), or any signs of a severe allergic reaction to vaccines (difficulty breathing, facial swelling, widespread hives) — seek emergency care immediately if these occur.
Section-by-Section Breakdown
What to include in each section and why it matters.
Subjective
In pediatric SOAP notes, the subjective section is primarily reported by the caregiver rather than the patient. Document developmental milestones across all domains — speech and language, fine motor, gross motor, social-emotional, and self-care skills like toileting — using specific examples rather than vague statements like 'developing normally.' Include dietary intake details (types of food, milk quantity, fluid intake) because nutritional sufficiency directly affects growth and development. Sleep patterns, screen time, and behavioral observations (frequency, duration, and response to redirection of tantrums) provide critical context for developmental assessment. Document the home environment including safety factors (firearms storage, smoke detectors, tobacco exposure) because anticipatory guidance is a core component of pediatric well visits and must be tailored to the child's actual living situation.
Objective
Pediatric objective documentation requires growth parameters plotted on standardized growth charts with percentiles — weight, height, and BMI with their corresponding percentile values, plus a note about the trend over time (tracking consistently, crossing percentile lines). Include the results of age-appropriate standardized developmental screening tools such as the ASQ-3 with domain scores and cutoff values to demonstrate that screening was performed, not just a clinical impression. Vision and hearing screening results must be documented with the method used. The physical examination should be systematic and age-appropriate — include Tanner staging for genital development, dental assessment (number of teeth, caries), and specific markers such as the cover-uncover test for strabismus. Immunization documentation must include vaccine name, manufacturer, lot number, expiration date, injection site, dose, route, and that VIS was provided and consent was obtained — this is both a legal and a Vaccines for Children (VFC) program requirement.
Assessment
The pediatric assessment interprets objective findings in the context of age-appropriate norms and developmental expectations. Rather than simply stating 'development is normal,' reference the specific screening tool results (ASQ-3 scores above cutoffs in all domains). Address each parental concern explicitly — for example, explain that the tantrum frequency is within the developmentally typical range for a 4-year-old and specify why it does not meet criteria for a behavioral disorder. Normalize nighttime enuresis by citing the expected age range for nocturnal continence. Comment on growth trajectory stability, not just single-visit measurements. Flag any findings that require monitoring over time (picky eating, isolated café-au-lait spot) and explain the clinical reasoning for why intervention is or is not warranted at this stage.
Plan
The plan for a pediatric well-child visit centers on anticipatory guidance — age-specific counseling on nutrition, safety, behavior, dental care, physical activity, and media use. Document each guidance topic with enough specificity that another clinician can see exactly what was discussed and what recommendations were given (transition to low-fat milk, 1000 mg calcium target, car seat guidelines with weight thresholds). Include the timing and components of the next well-child visit. Provide clear return precautions specific to the visit — for vaccination visits, specify the temperature and duration thresholds that warrant a call, and list signs of a severe allergic reaction with instructions to seek emergency care. This level of detail demonstrates that comprehensive well-child care was delivered, not just a physical exam.
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