Pediatrics
Pediatric SOAP note template
A SOAP structure adapted for children: history is taken from a caregiver, weight drives every prescription, and growth, feeding, immunisation status and development belong in the record.
Best used for
- Well-child visits
- Febrile infants
- Pediatric urgent care
- Immunisation reviews
Template structure
Each section shows what to document and a worked clinical example.
Record who gave the history and their relationship to the child. Cover feeding, wet nappies or fluid intake, activity level, sleep, sick contacts and immunisation status.
Example
History from mother. Two days of fever to 38.9 C, reduced oral intake, four wet nappies in 24 hours. Playful between fevers. Immunisations up to date. Older sibling with similar illness.
Weight with centile, vital signs interpreted for age, hydration status, and a full systems examination including ENT, chest, abdomen and skin.
Example
Weight 12.4 kg (50th centile). T 38.4 C, HR 132, RR 28, SpO2 98%. Alert, well perfused, moist mucous membranes. Right tympanic membrane erythematous and bulging. Chest clear.
State the diagnosis with severity, explicitly comment on hydration and red flags, and note whether the child meets criteria for safe discharge.
Example
Acute otitis media, right, in a well-hydrated child. No features of sepsis or meningism. Safe for outpatient management.
Prescribe by mg/kg and show the calculation. Give caregiver education, clear return criteria and the follow-up interval.
Example
Amoxicillin 80 mg/kg/day divided twice daily = 500 mg twice daily for five days. Paracetamol 15 mg/kg as needed. Return if fever beyond 48 hours, ear discharge, neck stiffness or reduced fluid intake. Review in one week.
Documentation tips
- Always document the weight used for dosing — it is the single most audited element of a pediatric note.
- Note who provided the history; caregiver accounts vary in reliability.
- Record the specific return criteria you gave, not just 'safety-netting advice given'.
Frequently asked questions
- How is a pediatric SOAP note different from an adult one?
- History comes from a caregiver, vital signs must be interpreted by age, weight and growth centile are mandatory, and dosing is weight-based.
- Should growth centiles be in every pediatric note?
- Weight belongs in every note because it drives dosing. Full growth centiles are essential at well-child visits and any presentation involving feeding or weight concerns.
- What red flags should a pediatric plan address?
- Dehydration, respiratory distress, altered consciousness, non-blanching rash and persistent fever — state which you excluded and what should prompt return.
- Does ScribeMDPro support pediatric documentation?
- Yes. Recordings of caregiver-led consultations are drafted into this structure, and the clinician reviews every field, including dosing, before approval.
More templates
Let ScribeMDPro draft your pediatrics notes.
Record the visit, review the draft, approve. The structure on this page is generated for you.