Well-child SOAP Note Format
Demographic Data
· Age, and gender (must be HIPAA compliant)
Subjective
· ___-day/week old infant/child accompanied by ___________ and here for a routine well-child/baby check (and vaccines). Any parental concerns/ questions today?
· Interval Events/History:
· Nutrition:
· Elimination:
· Sleep:
· Medications:
· Allergies:
· Past Medical
·
· Pregnancy and delivery?
· Surgeries, hospitalizations, or serious illnesses to date?
· Immunizations?
· Development: (describe as applicable to age)
·
· Gross motor:
·
· Fine motor:
· Cognitive:
· Social/Emotional:
· Communication:
· Social History:
· Smoking in the home?
· Family life/structure/dynamics? Primary caregivers?
· Stressors?
· Family History:
Objective (Should be a thorough head to toe assessment)
· Vital Signs/growth measurements (weight, length, head circumference, BMI, BP, HR, etc. if applicable)
·
· Physical findings listed by body systems, not paragraph form.
· Highlight abnormal findings
· Growth Chart Percentages: if applicable
· Labs/Studies: if applicable
Assessment
· Well-child visit ICD10 code(s)
Plan
· Vaccines today:
· Anticipatory guidance (discussed or covered in the visit)?
· Health Maintenance
· Return precautions?