SOAP note

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Infectious diseases (not related to vaccines), genetic disorders or pain

  • Make sure that you’re using appropriate PEDIATRIC questions for the HPI/ROS/Hx and appropriate exam findings. For example, you would not ask whether or not the patient is experiencing chest pain/dizziness for a 4 month-old-infant.
  • ALL SOAP notes should include basic biological functioning assessment, growth curves and percentiles with vital signs, etc…. A well visit SOAP does not need differential diagnoses, but rather a detailed, comprehensive documentation.
  • SOAP notes must be detailed and include at least 3 differential diagnoses related to the final diagnosis. Make sure you know the difference between “actual” and “differential” diagnoses.
  • Current clinical guidelines need to be included/cited with all SOAP notes. If the plan of care did not follow the current guideline, then you need to discuss why when you reflect on the visit. References and intext citations must be in complete APA format.
  • When you prescribe a medication, then include the dose recommendation, the strength of the medication, frequency, route, amount to be dispensed and refills. This process will help you learn how to write a prescription, which is very important in pediatrics since most medications are weight based. An example: For strep pharyngitis the recommended antibiotic is amoxicillin @ 50 mg/kg/day divided q12hr. Child’s weight = 17 kg = 850 mg/day. Amoxicillin’s strength = 400 mg/5 mL. Therefore the child is to take 5 mL po q12 hr x 10 days. Dispense 100 mL with 0 refills.
  • Make sure to keep the SUBJECTIVE data (what the family/patient tells you) separate from your OBJECTIVE data (what you see, feel, hear, measure, etc..).
  • These SOAP notes will be graded using the grading rubric provided with each weekly assignment. For more details of the elements of a great SOAP note, please see the document saved in Doc Sharing entitled Elements of a Great SOAP Note.

Remember to due self assessments on each SOAP subject

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