Basic SOAP Note Template - Pediatrics

Chief Complaint

[The Chief Complaint is the primary symptom or issue that leads a patient to seek medical attention. Provide a brief and clear statement describing the main symptom, problem, condition, diagnosis, or reason for the patient's visit.]

History of Present Illness

[Focus on the patient's chief complaints. Include details such as onset, duration, severity, timing/frequency, alleviating/aggravating factors, and location-based nature of the issues. Incorporate input from the parent/guardian if applicable. Note any triggering events or associations with major life events. Document what has been done for the problem so far and whether these interventions have been effective.] (List items with bullet, and each item in a new line. )

Sleep History

[Provide a detailed narrative of the patient's sleep habits, parasomnia symptoms, and associated signs and symptoms. Include information on sleep schedule, nighttime awakenings, total sleep hours, parasomnia symptoms (e.g., sleepwalking, night terrors), and any associated symptoms (e.g., morning headaches, excessive daytime sleepiness).] (List items with bullet, and each item in a new line. )

Development

[Provide an overview of the patient's growth and developmental milestones, including motor skills, language, cognitive development, and social/emotional development. Include parental observations, concerns, and any assessments performed. Leave empty if no such items found.] (List items with bullet, and each item in a new line. )

Past Medical History

[Record details about the patient's past medical conditions, including onset, duration, and treatments. Include relevant prenatal, perinatal, and postnatal history, as well as any hospitalizations or ER visits. Do not duplicate information from the surgical history.] (List items with bullet, and each item in a new line. )

Past Surgical History

[Document all past surgeries, specifying the type of surgery, body part involved, year performed, and surgeon or facility if known. Include any complications or relevant details. If no surgical history exists, explicitly state this.] (List items with bullet, and each item in a new line. )

Past Psychiatric History

[Record any past psychiatric conditions, diagnoses, or significant symptoms, including treatment details. Include conditions such as depression, anxiety, ADHD, or PTSD if mentioned.] (List items with bullet, and each item in a new line. )

Allergies

[Document any known allergies to medications, foods, or environmental factors. If no allergies are reported, explicitly state 'No known allergies' or similar.] (List items with bullet, and each item in a new line. )

Current Medications

[List all current medications, including over-the-counter drugs and supplements. Include details such as medication name, dosage, frequency, and route. Document any pertinent negatives, adherence issues, or side effects discussed.] (List items with bullet, and each item in a new line. )

Immunizations

[Document the patient's immunization history, focusing on any relevance to sleep health. Include recent vaccinations and any side effects that may impact sleep patterns.] (List items with bullet, and each item in a new line. )

Family History

[Provide a narrative of the patient's family history, focusing on medical and psychiatric illnesses. Include any relevant conditions such as sleep apnea, asthma, or allergies.] (List items with bullet, and each item in a new line. )

Social History

[Record details about the patient's social history, including major life events, school performance, family/home situation, and social activities.] (List items with bullet, and each item in a new line. )

The Review of Systems

[Document symptoms reported by the patient across all body systems. Include both positive and pertinent negative findings explicitly stated in the encounter. Focus on symptoms relevant to sleep medicine.] (List items with bullet, and each item in a new line. )

Vital Signs

[Record vital signs such as blood pressure, heart rate, respiratory rate, oxygen saturation, temperature, height, weight, and head circumference. Include any relevant findings explicitly stated.]

Physical Examination

[Document objective findings from the physical examination. Include normal and abnormal results, systematically organized by body system. Use formal medical terminology and avoid subjective interpretations.] (List items with bullet, and each item in a new line. )

Investigations

[Enter laboratory test results and any questionnaire or test scores (e.g., Epworth Sleepiness Scale, PHQ-9). Use formal medical terminology and provide complete sentences.] (List items with bullet, and each item in a new line. )

Impression

[List the main health issues or diagnoses related to the chief complaints. Include ICD-10 codes and a detailed description of symptoms or findings. Do not include irrelevant past medical history diagnoses.]

Differential Diagnosis

[Provide a systematic summary of potential diagnoses based on symptoms, history, and findings. Include a brief explanation for each diagnosis. If no differential diagnosis is conducted, leave this section null.] (List items with bullet, and each item in a new line. )

Plan

[Detail planned investigations, referrals, treatments, and patient education. Include information about medications (dosage, frequency, route), behavioral interventions, and follow-up plans. Use past tense for actions already taken and present tense for ongoing or future recommendations.] (List items with bullet, and each item in a new line. )

Plan

[Detail planned investigations, referrals, treatments, and patient education. Include information about medications (dosage, frequency, route), behavioral interventions, and follow-up plans. Use past tense for actions already taken and present tense for ongoing or future recommendations.] (List items with bullet, and each item in a new line. )