How to Write Professional SOAP Notes for Pediatric Well Visits

Kids grow up fast and so does the pile of notes you need to finish after every well visit.

I built SOAP Notes Doctor because I know the struggle of balancing quality care with good documentation. A great SOAP note should capture everything from growth charts to parent concerns in a way that's clear, thorough, and quick to write.

Here's how I do it and how you can too.

SOAP Notes 101

Before SOAP notes came along, medical records were… kind of a mess. Everyone had their own style, and finding key information was like digging through a junk drawer.

This happened until Dr. Lawrence Weed, a physician who believed medical notes could be standardized and problem-focused, came around. In the late 1960s, he came up with the SOAP format and it stuck. Today, SOAP notes are used everywhere from hospitals to private practices.

The format is simple:

• S – Subjective: what the parent or patient reports
• O – Objective: what you measure, see, or observe
• A – Assessment: what you think is going on
• P – Plan: what you'll do next

How to Approach SOAP Notes for Pediatric Well Visit

Your SOAP note should be a complete, meaningful snapshot of a child's health and development at that moment in time.

I've seen too many notes that are either so bare they're unhelpful, or so long they're unreadable. The sweet spot is a SOAP note that is thorough, structured, but also efficient enough to get done without eating into your evening. That's the balance I believe every pediatric clinician should aim for.

The SOAP framework gives us the perfect outline, but for well visits, you need to tweak your mindset. Unlike sick visits, where the focus is on solving a problem, well visits are about documenting growth, preventing issues, and educating families. That means your SOAP note should feel proactive and anticipatory, not reactive.

Let's break down each section and how I recommend approaching them.

Subjective: Start With the Parent's (and Child's) Voice

In pediatrics, the "S" in SOAP often comes from the parents or caregivers, and sometimes even siblings who tag along. This is where you capture concerns, developmental milestones, and any changes since the last visit.

I always encourage clinicians to write this section in a way that honors the parent's perspective because they're the ones who see the child every day.

For example, instead of simply writing "No concerns," I prefer when clinicians document exactly what the parent says: "Mom reports child is eating well, sleeping through the night, and starting to use two-word phrases." This phrasing captures the nuance of development and is much more helpful if another provider picks up the chart later.

In well visits, the subjective section should also cover things like nutrition, sleep, behavior, social interactions, and school performance (for older children). The key here is to think: "What are the daily rhythms and routines that shape this child's health?" That's what belongs in the Subjective.

Quick tip: A good tip is to iterate on the SOAP Notes you got from soapnotes.doctor (if the need be). Add a rough observation using the tailorr button and you'll have write a better observation using industry best practice.

Objective: More Than Just Numbers

Pediatric well visits are full of measurements. Weight, height, head circumference (for infants), and vitals. These are important, but they're just the start. Developmental screenings, physical exam findings, and even your observations of how the child interacts with their caregiver belong here too.

I think too many SOAP notes in pediatrics underuse the Objective section. Rather than a place to dump numbers into percentiles, you should capture the child's current state in a way that future you (or another provider) can visualize.

For example:

• Instead of only writing "Normal physical exam," document "Alert, playful, made eye contact, able to climb onto the exam table independently."
• Instead of "Growth appropriate," write "Weight at 50th percentile, height at 45th percentile, BMI within normal limits."

When you take this approach, your Objective becomes a living record of how the child is growing and developing. In pediatrics, where so much depends on patterns over time, that detail matters.

Quick tip: A good tip is to iterate on the SOAP Notes you got from soapnotes.doctor (if the need be). Add a rough observation using the tailorr button and you'll have a beautiful observation using industry best practice.

Assessment: Your Professional Lens

The Assessment is where you interpret everything you've gathered. In a sick visit, this is often a diagnosis. But in a well visit, it's more of a statement about health, growth, and development.

My advice: don't undersell the value of your professional judgment here. Parents may have Google, but they don't have your trained eye to connect the dots.

For example, your Assessment might be as simple as: "Healthy 4-year-old male, meeting developmental milestones, no acute concerns." Or it might highlight a risk: "5-year-old female, overweight for age, discussed healthy diet and activity level with parents." Both are valuable.

I often tell clinicians: the Assessment should also include what could be while stating what is. This is where you document risk factors, emerging patterns, or areas that need monitoring. That's what elevates a SOAP note from a dry record to a true clinical tool.

Quick tip: SOAP Notes doctor will attempt writing an assessment and plan using industry standards and information provided. Feel free to edit.

Plan: Where Guidance Meets Action

For a SOAP Note, you should chart the future, both short-term (vaccines today, labs if needed) and long-term (return in 1 year, continue monitoring growth, encourage reading at bedtime). And you should do it here.

I recommend structuring the Plan in a way that makes it easy to scan. Bullet points are perfect here. Parents and caregivers often forget half of what was discussed in the visit, and your note may be the only written record.

Include things like:

• Immunizations given and due dates for the next set
• Anticipatory guidance (e.g., safety, screen time, dental care, school readiness)
• Referrals if needed (speech therapy, nutritionist, etc.)
• Follow-up interval

I think anticipatory guidance is one of the most undervalued parts of pediatric SOAP notes. Yes, vaccines and growth charts are important, but it's those conversations about helmets, literacy, and healthy habits that truly shape a child's long-term well-being. Documenting them in the Plan ensures that guidance doesn't get lost in the shuffle.

Conclusion

Writing effective SOAP notes for pediatric well visits is both an art and a science. By focusing on the parent's voice in the Subjective, capturing meaningful observations in the Objective, providing thoughtful interpretation in the Assessment, and creating actionable guidance in the Plan, you can create documentation that truly serves both your patients and your practice.

Remember, a great SOAP note isn't just about meeting documentation requirements—it's about creating a valuable record that supports continuity of care and helps children thrive.