Elements of a great SOAP note SUBJECTIVE data/information is the information that the patient/caregiver tells you and should not include any of your observations. The SUBJECTIVE portions of the SOAP note include: Chief complaint, child profile, HPI, medications, PMH, Family/social history and review of systems (ROS). Who is giving the history? What pt/caregiver(s) said in quotes. Child Profile: All visits should include the basic biological functioning assessment, which includes nutrition, elimination, sleep, school/daycare, relationships (friends/family), sports/activities, safety measures in place, and PAST developmental history (if applicable) – not current. HPI – is the History of the Present Illness – for episodic visits you need to include all pertinent questions to start developing your differential diagnoses. Use OLDCARTS. Medications taking and why (even OTCs) – these are for current meds and not the ones you prescribe at the current visit. Past Medical History – for immunizations pls list the vaccines received to date. For adolescent pts (12 yo +), only list the ones received after age 6 yo Nuclear family medical history Social history – who the pt LIVES with, living environment, safety features of the house, is he/she safe?, smoke/drugs/alcohol exposure? Review of Systems (still subjective) These need to be age specific and appropriate for the patient. You wouldn’t ask a 6 month old if she’s experiencing chest pain, for example. For well visits, you need to review ALL of the systems. For episodic/sick visits, you need to have a focused ROS. For example, you shouldn’t ask a pt coming in with a CC of pharyngitis if she’s having breast discharge. However, a basic ROS should always include questions regarding General, Cardio, Resp and GI, along with the CC. Medical/professional terminology should be documented in the ROS. Instead of saying “c/o sore throat” you should state “+pharyngitis.” OBJECTIVE data/information is any information that you can SEE, HEAR, FEEL or MEASURE. It includes vitals and the exam details. Growth curves: ALL SOAP notes must have growth curves either uploaded to the dropbox or copied/pasted onto the SOAP. You can take a picture of the growth curve in the chart on EMR (removing all pt identifiers) and paste into the SOAP note. OR you can get a blank growth curve online and plot the data, then upload. For pts from birth to 2 years you need HEIGHT, WEIGHT, and HEAD CIRCUMFERENCE. For pts >2 yo, then you need HEIGHT, WEIGHT, and BMI. Vital signs: use proper units (lb/kg, in/cm, F/C, etc…) The exam should use professional/medical terminology. For well visits: ALL systems have to be examined, including breast and GU. For these systems you need to document the Tanner stages, along with the description. For episodic visits: The exams should be focused, but should always include GENERAL, CARDIO, RESP, and GI. For well visits: This section should include any type of ASSESSMENT TOOL that you used, the name of the tool, the results and the rationale for the tool. For infants and early childhood you should always include a developmental assessment. For teens – any type of depression/behavioral/risky behavior screens. For episodic visits: This section is N/A unless the pt/caregiver expresses a concern OR if something is detected in the Child Profile/HPI/Social Hx/ROS. However, a HEADSSSVG should be performed at every adolescent visit. Primary diagnosis & Differential Diagnoses For well visits: You do not need a list of differentials if no abnormalities were detected. For episodic visits: You need to make sure you indicate what the primary diagnosis is and then give three RELATED differentials. Giving three actual diagnoses is not considered differentials. The differential diagnoses are a group of diagnoses that share common elements and should start to form in the HPI/ROS/Hx. The differentials are then narrowed with the exam and any test results. You will need to give a couple of sentences of why you chose the diff and how you rule it out. Plan of Care The plan of care needs to be detailed. You cannot say “Patient education given regarding safety practices.” This doesn’t let me know what YOU need to tell the patient. It should state, for a 2 month old infant for example, put to sleep on back, no blankets/stuff animals in crib – these will prevent SIDS. For medications you need to give the RECOMMENDED WEIGHT BASED DOSE. ALL meds in peds are based on a child’s weight and are determined by clinical guidelines. You should indicate this recommended weight based dose, as well as directions for taking the meds. You should also include education about potential side effects. All of the other components should be included, but are self-explanatory. **** Up to this point the SOAP is based on what you and/or your clinical preceptor did during this patient’s visit. If you preceptor gives you evidence-based (EB) guidelines, then you should indicate which one was used, along with the diagnoses and plan of care. However, the most important part of the SOAP note is the self-assessment, see grading rubric below. The SOAP note grading rubric (more detail one can be found with the assignment description) The Self-Assessment & Clinical Guidelines is one of the most important parts of the SOAP note. This portion is where you critically analyze what you and/or your clinical preceptor did during the visit and then you research CURRENT EB guidelines for the type of visit. You can always ask your clinical preceptor what EB guidelines they’re using and why (make sure they’re the most recent guidelines though). Once reading/learning about the EB guidelines, you examine to see if you/your clinical preceptor followed these guidelines. If you did, then how. If not, then you need to describe how it differed and why. Then you need to discuss what you would do differently for the next visit with a similar patient. Simply stating that “My preceptor and I followed EB guidelines and I would do nothing differently.” is not an acceptable self-assessment. Pediatric SOAP Note Name: Date: Sex: Age/DOB/Place of Birth: SUBJECTIVE Historian: Present Concerns/CC: Reason given by the patient for seeking medical care “in quotes” Child Profile: (Sexual History (If appropriate); ADLs (age appropriate); Safety Practices; Changes in daycare/school/after-school care; Sports/physical activity; Developmental Hx) HPI: (must include all components) Medications: (List with reason for med ) PMH: Allergies: Medication Intolerances: Chronic Illnesses/Major traumas: Hospitalizations/Surgeries: Immunizations: Family History (Please identify all immediate family) Social History Education level, occupational history, current living situation/partner/marital status, substance use/abuse, ETOH, tobacco, and marijuana. Safety status ROS General Cardiovascular Skin Respiratory Pediatric SOAP Note Eyes Gastrointestinal Ears Genitourinary/Gynecological Nose/Mouth/Throat Musculoskeletal Breast Neurological Heme/Lymph/Endo Psychiatric OBJECTIVE (plot height/weight/head circumference along with noting percentiles) Attach growth chart Weight Temp BP Height Pulse Resp General Appearance and parent‐child interaction Skin HEENT Cardiovascular Respiratory Gastrointestinal Breast Genitourinary Pediatric SOAP Note Musculoskeletal Neurological Psychiatric In-house Lab Tests – document tests (results or pending) Pediatric/Adolescent Assessment Tools (Ages & Stages, etc) with results and rationale For adolescents (HEADSSSVG Assessment) Diagnosis ➢ ➢ ➢ Include at least three differential diagnoses with ICD-10 codes. (Includes Primary dx and 2 differentials) Document Evidence based Rationale for ROS and each differential with pertinent positives and negatives Primary diagnosis ✓ Is #1 on list of differentials ✓ Evidence for primary diagnosis should be supported in the Subjective and Objective exams. PLAN including education ➢ Plan: Treatment plan should be for the Primary Diagnosis and based on EB literature. ➢ Include EB rationale for all aspects of your treatment plan: ✓ Vaccines administered this visit ✓ Vaccine administration forms given ✓ Medication-amounts and mg/kg for medications ✓ Laboratory tests ordered ✓ Diagnostic tests ordered ✓ Patient education including preventive care and anticipatory guidance ✓ Non-medication treatments ✓ Follow-up appointment with detailed plan of f/u *ALL references must be Evidence Based (EB)
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