How I Write SOAP Notes for Acute Otitis Media

SOAP Notes for Acute Otitis Media

If you're a healthcare provider, you've probably written more SOAP notes for acute otitis media than you can count.

With over 5 million cases diagnosed annually in the US alone, ear infections represent nearly 30% of all pediatric visits.

Yet despite how routine these cases seem, I've noticed that many providers still struggle with creating comprehensive, efficient documentation.

After building soapnotes.doctor and analyzing thousands of templates, I've learned what separates good ear infection documentation from great documentation.

The Backbone of Medical Documentation

Before 1968, medical records were basically creative writing exercises.

Doctors documented however they felt like it – some wrote novels, others scribbled fragments, and good luck if you were the next provider trying to figure out what actually happened during that patient visit.

This happened till Dr. Lawrence flipped switch by introducing SOAP Notes.

In a jiffy…

Subjective gets you oriented with the patient's perspective
Objective provides your measurable data and observations
Assessment is where your clinical expertise shines through your diagnostic reasoning
Plan maps out your next moves

Each section builds on the last, creating a complete picture of the patient encounter.

How I Navigate SOAP Notes for Acute Otitis Media

Here's the reality: you need a system that captures clinical nuance without slowing you down, and you need it to be consistent enough that your notes are useful for follow-up visits, quality metrics, and yes, even potential legal review.

Let me share the two approaches I recommend, and why I'm particularly passionate about one of them.

Approach 1: soapnotes.doctor

I'll be completely transparent here – I built SOAP Notes Doctor because I was frustrated with the status quo.

But even setting aside my obvious bias, this approach has fundamentally changed how providers handle acute otitis media documentation.

Here's how it works in practice: You're in the room with a crying 3-year-old and concerned parents.

Instead of juggling a laptop or scribbling notes while trying to examine squirming ears, you simply start recording.

The conversation flows naturally – you ask about symptom onset, discuss the child's fever pattern, explain your otoscopic findings to the parents, and outline your treatment plan.

Soapnotes.doctor processes that entire interaction and generates a comprehensive SOAP note that captures not just the clinical facts, but the context and reasoning behind your decisions.

The parent's description of the child tugging at their left ear for two days goes into Subjective
Your finding of a bulging, erythematous tympanic membrane with decreased mobility lands perfectly in Objective
Your assessment of acute otitis media with consideration of antibiotic resistance patterns in your community gets captured in Assessment
Your discussion about amoxicillin dosing, return precautions, and follow-up timing populates your Plan section

But here's what I love most about this approach: it doesn't just save time – it often improves the quality of documentation.

Soapnotes.doctor catches conversational details that might get lost in manual note-taking. When you explain to parents why you're choosing a particular antibiotic, or when you discuss the natural history of ear infections, those educational moments get preserved in your note. That's valuable information for any provider who sees this patient for follow-up.

Approach 2: The Manual Method (For the Traditionalists)

Here's my opinionated take: most manual SOAP notes for ear infections are either too sparse or unnecessarily verbose.

I've seen notes that simply say "ear pain, red eardrum, amoxicillin" – which might satisfy billing requirements but tells us nothing about clinical reasoning.

On the flip side, I've seen providers write novellas about straightforward cases, burning precious time on documentation that doesn't add clinical value.

The manual approach that actually works requires discipline and templates.

My Manual Method That Actually Works for AOM

If you like writing every note by hand, great — but most of us want accuracy without burning time. I call this the Three-Layer Approach — it saved me clinical hours and keeps documentation consistent.

Layer 1: Pre-visit Template Setup

Have a ready-made AOM template before the patient walks in. A focused template cuts decision fatigue and speeds charting. Include these fields:

Chief complaint (quick line):

"Patient presents with [duration] of ear pain ± fever ± hearing change."

Ear-specific ROS checklist (tick boxes):

Ear pain ☐
Fever ☐
Ear tugging ☐
Otorrhea ☐
Hearing loss ☐
Recent URI ☐
Vertigo ☐
Vomit/↓feeding ☐

Physical exam framework (bullet list you can tab through):

Vitals: (Temp)
General: well/irritable/toxic
Ears: External canal (wax, discharge), Tympanic membrane — position (normal/retracted/bulging), color (pearl/erythematous/opaque), landmarks (visible/obscured), perforation/otorrhea, pneumatic otoscopy result (normal/↓mobility)
Neck: cervical LAD
Hearing screen: (Weber/Rinne in older kids/adults)

Pro tip: Documenting TM bulging, erythema, or decreased mobility helps support the diagnosis of AOM on exam.

Layer 2: Shorthand System (Use During Visit)

Stop writing long sentences at the bedside. Use a short, consistent code you can expand later. Keep it predictable.

Suggested shorthand tokens (examples + what to expand into):

TM: Bulg L; Ery; ↓Mob (pneumo+)
→ Bulging, erythematous left tympanic membrane with decreased mobility on pneumatic otoscopy.

Otorrhea R
→ Right ear drainage present; consider perforation or otitis externa if canal inflamed.

AOM-sev
→ Severe acute otitis media (moderate–severe otalgia OR fever ≥39°C OR symptoms ≥48 h).

OBS48
→ Observation/watchful waiting for 48–72 hours with safety-net plan.

ABX-Amx HD
→ Start high-dose amoxicillin (if indicated).

Why these? They make the exam and decision obvious at a glance and reduce keystrokes. Use the same tokens for every AOM — speed + consistency.

Layer 3: Post-visit Polish (3–5 minutes)

Immediately after the encounter, spend 3–5 minutes converting shorthand into a clean SOAP entry and add the clinical reasoning and plan. This step is what separates "good" from "great" notes.

How to expand (example workflow):

Copy the shorthand line into Assessment
Paste a one-sentence justification (exam findings that support diagnosis)
Add the plan line (drug/dose or OBS) and clear return/follow-up instructions

Example Shorthand → Full SOAP Snippets

A. Immediate Antibiotic (Child, Meets Treatment Criteria)

Shorthand:

CC: L ear pain x2d; TM Bulg L, Ery, ↓Mob (pneumo+); T 38.6°C; AOM-sev. Plan: ABX-Amx HD, analgesia, FU 48-72h.

Expanded (copy-paste ready):

Assessment: Acute otitis media — left ear. Supported by a bulging, erythematous tympanic membrane with decreased mobility on pneumatic otoscopy and fever.

Plan: Start high-dose amoxicillin (80–90 mg/kg/day PO divided twice daily) because of severity. Provide acetaminophen/ibuprofen for pain. Return or call if worse or no improvement within 48–72 hours; recheck if persistent symptoms.

B. Observation / Safety-net (Nonsevere Child)