Pediatric SOAP Note

• Patient Name

• Assigned Medical Practitioner

• Conducted on

  Date
• Location
  Address

Subjective Data

• Age

• Race

• Gender

• Chief complaint

• History of Present Illness (location, quality, severity, timing, setting, alleviating/ aggravating factors, associated signs and symptoms)

• Past Medical History (allergies, current medication, injuries, hospitializations, surgeries)

• Family History

• Social History

• Review of Systems

Objective Data

• Height (in)

• Weight (lbs)

• BMI

• Temperature

• Blood Pressure (BP)

• General Appearance

• EENT (Eyes, Ears, Nose, Throat)

• Cardiovascular

• Respiratory

• Integument/ Lymphatic Inspection

• Laboratory Results

Assessment

• General Observations

• Differential Diagnosis

Plan

• Treatment Plan

Completion

• Name & Signature of Attending Medical Practitioner

  Sign