Pediatric SOAP Notes

• The younger the patient, the more the Subjective section will rely on statements made by the parents or guardians of the children.  Any information about the patient's hospital course that is provided by nursing can also be placed in this section (e.g., "patient slept poorly", "patient complained throughout the night of a sore throat", "patient is homesick").  Also, the younger the patient, the more this section focuses on vegetative items  such as sleep, and po intake.  For older children, psychiatric issues, patient concerns, and any other complains should be included.
•  The first part of the Objective section is vital signs.  In pediatrics there are two additional vital signs: the daily weight and pulse oximetry readings.  Daily weight is helpful in determining hydration status, and for small children, for evaluating growth.  The pulse oximeter, when working properly, can provide insight into the patient's oxygenation and is often used as a parameter for adjusting the patient's oxygen supply.  All vital signs should be listed as a range over the previous 24 hours.  For temperature, the maximum temperature and the present temperature should be recorded.  If any trend is perceived, for example if the patient has grown increasingly tachypneic, indicate this.
• Under the vital signs, list the Ins and Outs.
• Ins:  Include any input such as iv fluids, po intake, NG tube or G-tube feedings.  Add all of the Ins for the last 24 hours and state this volume.  To make this number useful, calculate it in both cc/kg/day and as a percent of the patient's maintenance fluid requirement.  For infants or patient's with special nutritional needs, calculate the number of calories from all sources and express this as Kcal/kg/day.
• Outs:  List all outputs such as urine output, colectomy output, emesis, chest tube drainage.  Add them up over a 24 hour period and state this volume.  Urine output is usually expressed in cc/kg/hour.  Any qualitative comments about output should be made here, e.g. dark urine, yellow-seedy stool, green exudate.
• Fluid Balance = In - Out.  If positive, the patient contains more fluid than a day ago.
• If strict measurements of I/O are not recorded, list the number of urinations, stools, etc.
• The daily physical exam should always include general observations, HEENT, Lungs, Heart, Abdomen, Extremities, Skin and Neuro exam.  The remainder of the exam should be directed towards specific systems of concern.
• The Assessment and Plan section of the pediatric SOAP note are combined.  This section should begin with a short paragraph restating the patient's reason for being in the hospital, information about their current status, and any general comment regarding the overall plan.  Next, the A/P is divided by systems (like an ICU note).  In separate paragraphs, each system is evaluated and a plan is formulated.

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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