Pediatric SOAP Note Examples: Complete Guide for Healthcare Providers

If you've ever struggled to document pediatric visits in a way that captures developmental milestones, parental concerns, and growth parameters while meeting insurance requirements, this guide is for you.

I've talked to countless pediatricians, family physicians, and nurse practitioners who spend hours documenting well-child visits and sick visits, trying to balance comprehensive developmental screening with efficient charting.

The reality is that pediatric documentation has unique requirements that go beyond adult medicine.

Insurance companies want to see age-appropriate developmental assessments, growth tracking, immunization documentation, parental education, and evidence of preventive care.

That's exactly why I built SOAP Notes Doctor to handle the documentation complexity while you focus on connecting with young patients and their families.

In this article, I'll show you exactly how to write pediatric SOAP notes that meet insurance standards, with real examples you can adapt to your practice.

🧾 What SOAP Notes Really Are (And Why They Matter for Pediatrics)

SOAP notes might feel like bureaucratic busywork, but they serve a real purpose in pediatric care.

They were introduced in the 1960s by Dr. Lawrence Weed as part of the Problem-Oriented Medical Record (POMR).

His goal was straightforward: create a documentation system that anyone reviewing a chart could understand quickly and completely.

For pediatrics specifically, SOAP notes are critical because they demonstrate:

• Age-appropriate developmental progress and milestone achievement
• Growth tracking with percentiles for weight, height, and head circumference
• Comprehensive preventive care including immunizations and screenings
• Parental concerns addressed with appropriate education
• Medical necessity for referrals, procedures, or interventions
• Continuity of care across frequent visits during childhood

SOAP stands for:

• S — Subjective: What the parent/caregiver reports about symptoms, developmental concerns, feeding, sleeping, behavior, or what the older child reports themselves.
• O — Objective: Your clinical findings including vitals, growth parameters with percentiles, physical exam, developmental screening results, and any testing performed.
• A — Assessment: Your clinical diagnosis, developmental assessment, growth evaluation, and health maintenance status.
• P — Plan: Your treatment plan including medications, immunizations given, anticipatory guidance, referrals, and next visit timing.

This structure keeps your documentation organized, defensible, and insurance-friendly.

You're not just recording what happened—you're building a comprehensive picture of a child's growth, development, and health trajectory.

How You Can Approach Pediatric SOAP Notes

There's no single correct method for writing pediatric SOAP notes, but some approaches work better than others depending on your practice volume.

Here are two main approaches I've seen work well.

1. Traditional, Manual Documentation

This is the classic method: typing out each section after each visit. It works if you have consistent time built into your schedule and strong organization. The challenge is that pediatric visits pack in developmental screening, growth tracking, multiple immunizations, extensive anticipatory guidance, and often multiple parental concerns—all needing documentation.

2. SOAP Notes Doctor

You record your examination findings, developmental observations, and parental concerns, and the tool automatically structures everything into proper SOAP format. It maintains consistency across visits, saves significant time on well-child documentation, and ensures you never miss critical components like developmental milestones or anticipatory guidance topics.

How to Make Pediatric SOAP Notes Faster

One of the biggest complaints I hear from pediatricians is how documentation eats into their already packed schedules.

You've just finished a full day of well-child checks, sick visits, and worried parent phone calls, and instead of going home to your own family, you're stuck typing detailed notes documenting every developmental milestone and percentile.

The pressure is real: make them too brief and you risk missing developmental delays or billing issues; make them too detailed and you've just added hours to your evening.

Here's what we built to solve this:

✅ Head to soapnotes.doctor
✅ Record your examination findings or dictate observations
✅ Generate properly formatted SOAP notes instantly
✅ Spend more time with patients, less time charting

With soapnotes.doctor, you can record during or right after a visit, add rough notes about specific findings, or even upload audio later. The system converts everything into insurance-compliant SOAP notes automatically.

You still get the clinical accuracy and thoroughness that insurance companies require, but without manually typing every detail.

Maybe you noted specific findings?

"4yo WCV, height 102cm 50th percentile, weight 16kg 40th percentile, all vaccines UTD, speaks in complete sentences, knows colors, hops on one foot, no concerns."

Use the tailorr feature to add them. Keep it raw and unpolished—soapnotes.doctor handles the rest.

Example 1: Well-Child Visit, 4-Year-Old

Patient: 4-year-old female
Chief Complaint: Well-child check
Visit: Routine preventive care

S – Subjective:

Mother brings patient for 4-year well-child visit. No current concerns. Child attending preschool 3 days per week, adjusting well socially. Eating varied diet including fruits and vegetables, drinks whole milk. Sleeping 10-11 hours nightly without difficulty. Bowel and bladder habits regular, fully potty trained during day and night. No recent illnesses. Mother reports child speaks in full sentences, knows colors and some letters, plays cooperatively with peers, and follows multi-step directions. Active, enjoys playground activities. No behavioral concerns. Lives with both parents and older sibling. No secondhand smoke exposure. Car seat appropriate for age.

O – Objective:

Vital Signs: HR 95, RR 22, BP 95/60, Temp 98.4°F
Growth: Weight 16 kg (35 lbs, 40th percentile), Height 102 cm (40 inches, 50th percentile), BMI 15.4 (50th percentile)
General: Alert, active, cooperative, well-appearing
HEENT: Normocephalic, PERRLA, TMs clear bilaterally, oropharynx clear, dentition appropriate
Cardiovascular: Regular rate and rhythm, no murmurs
Pulmonary: Clear to auscultation bilaterally, good air exchange
Abdomen: Soft, non-tender, no organomegaly
Extremities: Full ROM, normal gait
Neurologic: Age-appropriate development, speech clear
Developmental Screening: Hops on one foot, throws ball overhand, copies circle, knows 4 colors, speaks in 5-6 word sentences, tells stories
Vision Screening: Passed Snellen chart at 20/30 bilaterally

A – Assessment:

Healthy 4-year-old female with normal growth and development. Growth parameters tracking along appropriate percentiles. Developmental milestones appropriate for age. Vision screening normal. Immunizations up to date. No concerns identified.

P – Plan:

Immunizations: All vaccines up to date per CDC schedule. Next vaccines due at 5-year visit.
Anticipatory Guidance: Discussed preschool readiness, continued emphasis on reading together daily, limiting screen time to less than 1 hour daily with high-quality programming, encouraging physical activity 3+ hours daily. Reviewed nutrition including limiting juice and sugary drinks, offering healthy snacks. Discussed safety including car seat use (should remain in harnessed car seat until outgrows limits), stranger danger awareness, water safety, poison prevention. Reinforced dental hygiene with twice-daily brushing, encouraged dental visit if not yet established.
Developmental: Continue to encourage social play, problem-solving activities, and creative play. Reading daily supports language development.
Follow-up: Return for 5-year well-child visit. Call with any concerns before then. Mother verbalized understanding and no additional questions.

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Example 2: Sick Visit, 18-Month-Old with Fever

Patient: 18-month-old male
Chief Complaint: Fever and decreased appetite for 2 days
Visit: Acute illness visit

S – Subjective:

Father reports patient developed fever 2 days ago, maximum temperature 102.5°F at home. Fussy and clingy, decreased appetite but drinking adequate fluids. No vomiting or diarrhea. Some clear nasal discharge. Cough occasional, not severe. No difficulty breathing. No rash. Sleeping more than usual. One other child at daycare reportedly sick with similar symptoms. Patient received acetaminophen with temporary fever reduction. No recent travel. Immunizations up to date. No known sick contacts outside daycare.

O – Objective:

Vital Signs: Temp 101.8°F, HR 135, RR 28, O2 sat 98% on room air
Weight: 11.5 kg (25 lbs, 50th percentile—unchanged from last visit)
General: Alert but irritable, consolable, adequately hydrated
HEENT: Clear nasal discharge, TMs bilaterally erythematous without bulging or effusion, throat mildly erythematous, no exudate, moist mucous membranes
Lymph: Small mobile anterior cervical nodes bilaterally
Cardiovascular: Tachycardic but regular rhythm, no murmur
Pulmonary: Clear bilaterally, no wheezing or crackles, good air movement
Abdomen: Soft, non-tender, active bowel sounds
Skin: No rash

A – Assessment:

Viral upper respiratory infection in 18-month-old. Likely viral etiology given clinical presentation, daycare exposure, and exam findings. No signs of bacterial infection. Hydration adequate. No respiratory distress.

P – Plan:

Treatment: Continue acetaminophen 160mg (5mL) every 4-6 hours as needed for fever or discomfort. Can alternate with ibuprofen 100mg (5mL) every 6-8 hours if needed for persistent fever. Encourage oral fluids. Nasal saline drops and bulb suction for nasal congestion.
Education: Reviewed that viral illnesses typically last 5-7 days. Fever is body's normal response to infection. Discussed signs requiring immediate attention: difficulty breathing, unable to keep down fluids, fever lasting more than 5 days, significantly decreased activity, or parental concern for worsening condition.
Isolation: Keep home from daycare until fever-free for 24 hours without medication.
Follow-up: Return if symptoms worsen or not improving in 3-4 days. Call immediately if warning signs develop. Father verbalized understanding of treatment plan and warning signs.

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Example 3: Newborn Visit, 2 Weeks Old

Patient: 2-week-old female
Chief Complaint: Routine newborn follow-up
Visit: Post-discharge newborn check

S – Subjective:

Mother brings infant for 2-week follow-up after hospital discharge. Born at 39 weeks via spontaneous vaginal delivery, birth weight 3.2 kg, uncomplicated nursery stay. Currently exclusively breastfeeding every 2-3 hours, 8-10 feeds daily. Latching well, feeding 15-20 minutes per side. Has at least 6 wet diapers and 3-4 stools daily, stools yellow and seedy. Umbilical cord stump fell off 3 days ago, healing well. Sleeping 16-18 hours daily in short intervals. Mother reports some mild jaundice noted in hospital but improving. No fever, vomiting, lethargy, or breathing concerns. Mother feeling overwhelmed but has family support. Father involved in care.

O – Objective:

Vital Signs: Temp 98.2°F, HR 145, RR 42
Weight: 3.4 kg (7 lbs 8 oz, 50th percentile—regained birth weight plus 200g)
Length: 51 cm (20 inches, 50th percentile)
Head Circumference: 35 cm (50th percentile)
General: Alert, active infant, appropriate for age
HEENT: Normocephalic, anterior fontanelle soft and flat, mild scleral icterus resolving, red reflex present bilaterally, TMs visualized and normal
Cardiovascular: Regular rate and rhythm, no murmur
Pulmonary: Clear, unlabored breathing
Abdomen: Soft, umbilicus clean and dry without erythema or discharge
Skin: Mild jaundice resolving, no rashes
Hips: Negative Barlow and Ortolani maneuvers
Neurologic: Appropriate tone, primitive reflexes intact

A – Assessment:

Healthy 2-week-old infant with appropriate weight gain and feeding pattern. Physiologic jaundice resolving as expected. Growth parameters normal. Breastfeeding established successfully. Umbilical cord healing normally. No concerns identified.

P – Plan:

Feeding: Continue exclusive breastfeeding on demand. Mother doing well with breastfeeding technique. Vitamin D supplementation 400 IU daily started (sample provided).
Jaundice: Mild physiologic jaundice improving clinically, no intervention needed. Encouraged continued frequent feeding to promote bilirubin excretion. Instructed mother to call if jaundice worsens or infant becomes lethargic.
Newborn Care: Reviewed safe sleep practices (back to sleep, firm surface, nothing in crib, room sharing). Discussed tummy time when awake and supervised. Reinforced umbilical care—keep clean and dry.
Maternal Support: Assessed for postpartum depression, mother reports adjusting well with support. Provided lactation consultant contact if needed. Encouraged mother to rest when baby sleeps.
Screening: Newborn screening and hearing screening completed in hospital, results pending (will follow up if abnormal).
Follow-up: Return for 1-month well-child visit. Call sooner if fever (temperature greater than 100.4°F), decreased feeding, fewer than 6 wet diapers daily, or any concerns. Mother verbalized understanding and no additional questions.

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Key Components Insurance Companies Look For in Pediatric SOAP Notes

When reviewing your pediatric documentation, insurance companies specifically want to see:

1. Growth Parameters with Percentiles

Weight, height/length, head circumference (if less than 2 years), and BMI (if greater than 2 years) plotted on growth charts with percentiles documented.

2. Developmental Screening

Age-appropriate developmental milestones documented, either through formal screening tools or clinical assessment showing the child is progressing normally.

3. Immunization Documentation

Vaccines given during visit or confirmation that immunizations are up to date per CDC schedule.

4. Anticipatory Guidance

Evidence that you provided age-appropriate education on safety, nutrition, development, and health maintenance.

5. Parental Concerns Addressed

Documentation that you listened to and addressed any parental worries or questions.

6. Clear Assessment of Illness Severity

For sick visits, clear documentation of why you chose observation versus treatment, or why referral/testing was or wasn't needed.

Common Mistakes to Avoid

Missing Percentiles: Don't just document weight and height—include percentiles to show growth trends and identify concerns.

Vague Developmental Assessment: Instead of "developing normally," document specific milestones observed or reported: "speaks 2-3 word phrases, walks independently, feeds self with spoon."

Forgetting Anticipatory Guidance: Insurance wants to see preventive counseling documented, especially for well-child visits.

Incomplete Immunization Documentation: Always note vaccines given with lot numbers and sites, or document why vaccines were deferred.

Not Documenting Parental Education: Show that you addressed questions and provided appropriate guidance.

Missing Comparison to Previous Visits: Growth and development should show trends over time, not just isolated data points.

Tips for Efficient Pediatric Documentation

Use Age-Based Templates: Create templates for common well-child visits (2-month, 4-month, 6-month, etc.) with pre-populated milestone checklists.

Standardize Anticipatory Guidance: Develop standard anticipatory guidance topics by age that you can quickly review and document.

Document While in the Room: Record growth percentiles and developmental observations as you assess the child.

Involve Parents in Documentation: Ask parents to complete developmental questionnaires before the visit that you can reference.

Batch Similar Components: For well-child visits, document immunizations, screening results, and growth parameters in consistent format.

Final Thoughts

Pediatric SOAP notes don't need to be overwhelming.

They need to be thorough, yes, but they don't need to consume your life.

The key is having a system that captures essential developmental, growth, and preventive care information without making you feel like you're spending more time documenting than examining.

Whether you write them manually or use a tool like soapnotes.doctor, the goal is the same: clear documentation that supports the child's health and development while satisfying insurance requirements.

Your time is better spent engaging with children and their families than typing repetitive documentation.

That's exactly why we built this tool.

Try it out, see how much time you get back, and let me know what you think.

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Ready to simplify your pediatric documentation?
Visit soapnotes.doctor and get your first notes generated in minutes.