Pediatric SOAP Notes

Like all SOAP notes, when another person reads a pediatric SOAP note, they should know everything there is to know about the current status of the patient, such that they could then step in and assume care of the patient.  You will appreciate this if you are ever consulted or cross-covering another patient.
 
Pediatric SOAP notes differ from adult-oriented notes in several important ways.  The main differences are as follows: Example

Subjective:   Pt slept well, no distress this am.  Mother reports pt more active last night than earlier in the day, less irritable.  Tolerating pedialyte well in smaller than usual volumes.

Objective:     T:36.3x - 36.7x         HR: 105-115        RR: 28-32         BP: 75-81/50-55
                    Tcurrent: 36.55
                    Tmax 36.7 (0400 today)

WT: 12.25 kg (up 250g from admission, up 100 g since yesterday)

Ins:     po:  300 cc
          iv:    1100 cc
          tl:    1400 cc = 114 cc/kg/day = 1.3 x maintenance

Outs:  1100 cc = 3.7 cc/kg/hour

Delta:  +300 cc

Gen:  Well appearing, NAD.  Resting comfortable.  Rousable.
HEENT:  NCAT, AFOF (not sunk).  PERRL, EOMI, +RR.  TMs translucent with good landmarks.  Eyes not sunken, +tears, noninjected.  No nasal d/c.  mmm.
CVS:  RRR, nl S1 and S2, no mm.
Lungs: CTA bilaterally, no wheezing, rales, rhonchi.  Excellent aeration.
Abd: + BS, soft, NTND, no mass, no organomegaly.
GU: perianal diaper rash, red, not raised, no satellite lesions, no yeasty in appearance, coated with desitin.  Appears improved.
Ext:  no c/c/e.  CFT less than 2 seconds.

Labs:  Chem-7 pending

A/P:  This is a 2 year old female with 2 day h/o decreased po intake, emesis, diarrhea, and low grade fever who was hospitalized for rehydration.  Based on positive rotavirus antigen assay, presumptive rotaviral gastroenteritis.  Pt is much improved today.

FEN:  Pt appears well hydrated.  No longer tachycardia, normal physical exam.  Positive fluid balance, brisk urine output.  IVF rate decreased to 1xM as pt attempts po.  Tolerating pedialyte 2-3 ounces q 2 hours.  Will try formula later today, as wean IVF based on po intake.

CVS:  Flow murmor heard while patient was febrile is no longer present.  No issues.

SOC:  Discussed viral gastroenteritis with parents who understand.  Mother will be here later today.  If good po intake, can d/c later today.  Family will need a taxi voucher for travel back to home.
 
General Pediatrics
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Last Modified June, 1996Last modification: February 21, 1998