Pediatric Developmental Assessment SOAP Note Template

Identifying information:
Name: Lucas
Age: 
Sex: 
Accompanied by: Parent
Reason for visit: Follow-up for attention-deficit/hyperactivity disorder management and evaluation of medication effectiveness.

Concerns / Presenting problem:
Lucas's parent reports that earlier in the year there were concerns regarding difficulty focusing in class, talking during lessons, and impulsivity. Lucas states that these symptoms have improved, particularly in science, with ongoing medication. However, he continues to find it difficult to focus in mathematics due to lack of interest. There is no mention of difficulty focusing in science. Parent also notes that Lucas has been more tired recently and has difficulty falling asleep despite going to bed by 9:30 PM. Appetite is reported as decreased, with Lucas eating little in the morning and not always finishing his lunch. The impact on daily functioning includes ongoing challenges with attention in certain academic subjects and mild changes in sleep and appetite.

Developmental history :
Gross Motor:
No significant findings.

Fine Motor:
No significant findings.

Language (Receptive & Expressive):
No significant findings.

Social & Emotional:
No significant findings.

Adaptive / Self-Help:
No significant findings.

Medical / Perinatal history:
No significant findings.

Family & social history:
No significant findings.

School / early learning history:
Lucas attends school and reports improved focus in science class since starting medication. He continues to have difficulty focusing in mathematics, which he finds uninteresting. He enjoys physical education and is active in basketball. Teacher reports are not provided.

Physical examination:
General & Growth:
Lucas's height is in the 85th percentile and weight is average, indicating no issues with growth.

Neurological:
No significant findings.

Dysmorphology / Syndromic Features:
No significant findings.

Hearing & Vision Check:
No significant findings.

Observation of play & behaviour :
- Engages in conversation with examiner and parent
- Demonstrates awareness of personal interests (basketball)
- Reports increased confidence during sports activities
- Attentive and cooperative during the encounter

Assessment / impression:
- Attention-deficit/hyperactivity disorder, with reported improvement in focus and behavior on current medication regimen
- Mild ongoing difficulty with attention in mathematics
- Mild sleep disturbance and decreased appetite, likely related to medication
- No concerns regarding growth or gross/fine motor development

Plan:
Continue current medication regimen for attention-deficit/hyperactivity disorder. Monitor sleep patterns, appetite, and school performance. Provide parent education on nutrition, sleep hygiene, and limiting sugary beverages. Recommend using a visual checklist for morning routines. Follow-up scheduled for summer. No medication adjustments indicated at this time.