Pediatric Developmental Assessment SOAP Note Template

Identifying information

Name: [Insert patient's full name] Age: [Insert patient's age] Sex: [Insert patient's sex] Accompanied by: [Insert name and relationship of parent/caregiver if present] Reason for visit: [State reason for visit, e.g., routine developmental check, concern about speech, behavioural changes, etc.]

Concerns / Presenting problem

[Document parent/caregiver concerns in their own words. Describe onset, course, and context of presenting problem. Describe impact on daily functioning (home, daycare, school). List any red flags already identified.]

Developmental history

[Use a structured domain approach: Gross Motor, Fine Motor, Language, Social-Emotional, Adaptive/Self-Help.] Gross Motor: [Describe milestones: rolling, sitting, crawling, walking, running.] [Comment on gait pattern, posture, coordination, and balance.] Fine Motor: [Describe grasp pattern, hand preference, manipulation skills (stacking, drawing, using utensils).] Language (Receptive & Expressive): [Document first words, combining words, understanding commands, speech clarity/articulation.] Social & Emotional: [Describe eye contact, joint attention, peer interaction, imitation, shared play.] Adaptive / Self-Help: [Describe feeding (texture tolerance, cutlery use), dressing skills, toileting.]

Medical / Perinatal history

[Summarize pregnancy and birth history: gestational age, mode of delivery, complications, NICU admission.] [Document newborn screenings.] [List relevant medical issues (e.g., seizures, chronic illness).] [List current medications and allergies.]

Family & social history

[Document family history of developmental or learning disorders. Describe home environment and primary caregivers. List languages spoken at home. Comment on screen time, sleep patterns, and nutrition.]

School / early learning history

[Describe school or daycare attendance. Summarize teacher reports, learning concerns, and behavioural observations.]

Physical examination

[Include developmental-relevant components:] General & Growth: [Document vitals, weight, height/length, head circumference.] [Include growth chart percentiles and trend.] Neurological: [Describe tone (hypotonia/hypertonia), strength, reflexes (primitive and postural), coordination, gait.] Dysmorphology / Syndromic Features: [Describe facial features, extremities, skin findings (e.g., Café au lait spots).] Hearing & Vision Check: [Document red reflex, audiology results, and parental concerns.]

Observation of play & behaviour

[Describe as a bulleted list engagement with caregiver, response to name, attention span, problem-solving skills, fine/gross motor behaviours observed.]

Assessment / impression

[State as a bulleted list overall assessment: normal development, mild delay, global developmental delay, etc.] [Comment on behavioural concerns if any (e.g., ADHD, ASD features, sensory concerns).] [Describe learning concerns if present.]

Plan

[List referrals (e.g., speech therapy, OT, PT, psychology, audiology).] [List investigations (e.g., hearing test, iron studies, genetic testing, imaging—if indicated).] [Document parent education provided (e.g., developmental stimulation advice).] [Recommend schedule for follow-up.] [Provide safety/red-flag advice.] [State if handouts or developmental milestone sheets were provided.]