Pediatric SOAP Note Example: 4 Samples + Template

A pediatric SOAP note has to do three jobs at once: capture the visit clearly, hold up in an audit, and support the codes on the claim. When the note doesn't support the codes, a clean visit still gets downcoded, denied, or clawed back on audit. 

This pediatric SOAP note example shows how each section is charted for kids and how the note carries the claim it's tied to.  

What Is a Pediatric SOAP Note?

A SOAP note records a visit in four parts: Subjective, Objective, Assessment, and Plan. The structure is standard across medicine, but pediatric notes include details specific to children, such as growth percentiles, developmental milestones, and a history often provided by a parent. 

An infant can't describe symptoms, so the subjective section relies on caregiver observation, and the note should always state who provided the history.

Done well, a pediatric SOAP note tracks a child across visits, hands the next clinician a clear picture, and documents the reasoning behind each decision. It also feeds the pediatric coding that the claim depends on, which is where many clean visits lose money.  

Pediatric SOAP Note Format: Section by Section

The table is the quick view. Here's what goes into each section, and where pediatric notes differ from adult ones. 

S: Subjective

The subjective section is the story: what the parent or child reports. Lead with who's giving the history, since that context shapes everything that follows in pediatrics. 

Include the chief complaint in the caregiver's or child's own words, then the history of present illness: onset, duration, timing, what makes it better or worse, associated symptoms, and anything tried at home.

Round it out with the pieces pediatrics depends on. This includes past medical and birth history, medications, allergies, immunization status, family and social history, and developmental history for younger children.

O: Objective

The objective section is what you measure and observe. Start with vital signs and growth data (weight, length or height, head circumference for infants), plotted against percentiles, since a number off the curve is often the first clue.

Then document the focused physical exam by system in plain language, with specific findings rather than vague reassurance. Add any in-office tests (rapid strep, urinalysis, glucose) with their results. Write only what you examined.

For a child born preterm, plot and interpret against corrected age — age counted from the due date rather than the birth date, through about 2 years. Chart both ages explicitly. It is the single biggest source of false alarms on growth percentiles, milestone checklists, and screening scores, and the next pediatrician can't reconstruct it from a birth date alone.

A: Assessment

The assessment is your clinical judgment. State the primary diagnosis and any secondary or chronic conditions, and add a short differential when the picture isn't clear. Make it age-appropriate and specific.

For example, "acute otitis media, right ear," says more than "ear problem." Note severity and relevant risk factors, since that's what justifies the plan and the code that follows.

P: Plan

The plan is what happens now and in the near future. Keep it specific enough that another clinician or the parent could follow it.

Cover diagnostics, medications with weight-based dosing (mg/kg, route, frequency, duration), non-drug care, and caregiver education with red-flag signs and a return timeframe. Document what you taught and that the caregiver understood it, since that line matters clinically and medicolegally.

For immunizations, your documentation needs more than "vaccines given": vaccine and manufacturer, lot number and expiration, site and route, the VIS edition date and the date it was handed over, who administered it, and the child's VFC eligibility category. Refused vaccines and refusal reasons should also be documented.

Pediatric Vital Signs by Age 

Vital signs shift with age, so a "normal" heart rate for a newborn would be tachycardia in a teenager. Use these ranges when you're plotting the Objective section. The values below follow the American Heart Association's PALS reference standards, as published by the HHS CHEMM database.

Heart rate (beats/min)

Respiratory rate (breaths/min)

For blood pressure, watch the hypotension threshold: below 60 mm Hg systolic for term neonates, below 70 for infants 1 to 12 months, below 70 + (age in years × 2) for ages 1 to 10, and below 90 for children over 10.

A rectal temperature of 38.0°C (100.4°F) or higher counts as a fever. In a well-appearing infant 8 to 60 days old, that reading triggers the AAP febrile infant workup and requires prompt evaluation, and fever in an infant under 28 days is handled as an emergency.

Charting by Age: Infants to Adolescents 

The SOAP structure remains the same at every age, but what fills each section changes as the child grows. A quick guide:

Infants (0–12 months)

The history is entirely caregiver-reported. Plot weight, length, and head circumference every visit, and chart feeding (breast or formula, amounts), voiding, and stooling, since those are your early clues to how a baby is really doing. 

Common sick visit presentations skew toward otitis media and bronchiolitis. Weight-based dosing isn't optional here because it's the whole safety margin.

Toddlers (1–3 years) 

The toddler may point or use a few words, but the parent still carries the history. Track growth velocity, run developmental surveillance at every visit and standardized screening on the AAP schedule — a general-development tool such as PEDS or SWYC at 18 and 30 months, and M-CHAT-R for autism at 18 and 24 months — and document anticipatory guidance on safety. Expect frequent viral URIs, ear infections, and gastroenteritis.

School-Age (4–11 years) 

The child starts giving their own history; chart what they report alongside the parents'. Add school performance, behavior, and vision and hearing screening, and watch BMI trends across visits. This is where the curve tells you more than any single reading. 

Adolescents (12+ years)

Interview the teen directly and offer a confidential time when the caregiver is not present. Document who was present, note consent and confidentiality per your state's law, and cover the psychosocial history (a HEADSS-style review) plus mood screening (PHQ-A). 

Confidentiality doesn't end at the note. A confidential service billed to a parent's plan generates an explanation of benefits that goes to the policyholder, which is how a documented-as-confidential visit gets disclosed anyway. Ask what your system does with the claim, not just the chart — some states let a minor request confidential communications, and a few suppress the EOB for sensitive services.

Pediatric SOAP Note Examples

Each pediatric SOAP note example below covers a common presentation across a different age band. Adapt the wording to your own clinical voice.

Example 1: Viral Upper Respiratory Infection (Toddler, Age 2)

Subjective: History from mother. Chief complaint: "Stuffy nose and low fever for three days." Mateo is a 2-year-old boy with nasal congestion, clear rhinorrhea, and a wet cough. Fever peaked at home at 38.4°C (101.1°F). He's clingier than usual but still eating and playing, with no trouble breathing, no wheeze, and no vomiting. Attends daycare, where two children have colds. No known allergies. Full-term birth, no chronic conditions, immunizations current.

Objective: T 38.1°C (100.6°F), HR 124, RR 28, SpO₂ 98%, weight 12.6 kg (50th percentile). Well-appearing, active, no distress. Moderate nasal congestion with clear discharge; tympanic membranes normal bilaterally; oropharynx mildly red, no exudate. Lungs clear, no wheeze or retractions. Heart regular rhythm. Abdomen soft, nontender. No rash.

Assessment: Acute viral upper respiratory infection in a well-appearing 2-year-old, with no signs of respiratory distress.

Plan: Supportive care with fluids, rest, saline nasal drops, and a cool-mist humidifier at night. Acetaminophen 15 mg/kg orally every 6 hours as needed for fever, no more than 4 doses in 24 hours. Educated mother on red-flag signs: fast or labored breathing, chest retractions, refusing to drink, or fever lasting past four days. Told her to return or seek emergency care if any appear. Follow up in three to four days if symptoms don't improve. Mother verbalized understanding.

Codes this note supports: J06.9 with an established-patient sick visit E/M (99212–99215), leveled on medical decision making.

Example 2: Acute Otitis Media (Infant, Age 10 Months)

Subjective: History from father. Chief complaint: "Pulling at her right ear and waking overnight." Aria is a 10-month-old girl who has been fussy since yesterday, tugging at her right ear, with a fever to 38.6°C (101.5°F) this morning. Sleeping poorly and eating less, but still taking the bottle. No vomiting or diarrhea, no recent antibiotics. Full-term, immunizations current, no chronic conditions.

Objective: T 38.3°C (100.9°F), HR 144, RR 34, SpO₂ 98%, weight 9.1 kg (55th percentile). Fussy but consolable in father's arms. Right tympanic membrane red and bulging with poor mobility on insufflation; left ear normal; mild, clear nasal discharge. Lungs clear. Heart regular. Abdomen soft. No rash.

Assessment: Acute otitis media, right ear, with associated fever.

Plan: Amoxicillin 80 to 90 mg/kg/day orally divided into two doses (max 2 g/day) for 10 days. Acetaminophen 15 mg/kg orally every 6 hours as needed for pain or fever, no more than 4 doses in 24 hours. Educated father on expected improvement within 48 to 72 hours and on red-flag signs: poor feeding, fever that persists or climbs, worsening fussiness, or drainage from the ear. Told him to return sooner if any appear. Follow up in two to three days if not improving. Father verbalized understanding.

Codes this note supports: H66.91 (otitis media, unspecified, right ear) with an established-patient sick visit E/M (99212–99215).

Example 3: Viral Gastroenteritis With Mild Dehydration (Preschooler, Age 3)

Subjective: History from mother. Chief complaint: "Throwing up and diarrhea since yesterday." Eli is a 3-year-old boy with about a day of non-bloody, non-bilious vomiting (three episodes) and several loose, watery stools, plus a low fever to 38.2°C (100.8°F). Taking small sips but refusing solids. Last wet diaper about six hours ago. No blood in stool, no severe abdominal pain. A cousin had similar symptoms last week. No known allergies. Full-term, immunizations current, no chronic conditions.

Objective: T 38.2°C (100.8°F), HR 128, RR 26, SpO₂ 99%, weight 14.8 kg (60th percentile). Tired but alert and responsive. Lips slightly dry, eyes not sunken, capillary refill about 2 seconds, tears present. Abdomen soft with active bowel sounds, mild diffuse tenderness, no guarding. Skin turgor is normal. No rash.

Assessment: Acute viral gastroenteritis with mild dehydration in a 3-year-old.

Plan: Oral rehydration with an electrolyte solution, small amounts every few minutes, then advance the diet as tolerated. Reviewed oral rehydration technique with mother. No routine antidiarrheals. Educated mother on red-flag signs: no urine for eight or more hours, no tears when crying, lethargy, blood in stool, or persistent vomiting that blocks fluids. Told her to return or seek emergency care if any appear. Follow up by phone in 24 hours, sooner in person if worsening. Mother verbalized understanding.

Codes this note supports: A08.4 (viral intestinal infection, unspecified) plus E86.0 for the dehydration, with an established-patient sick visit E/M (99212–99215).

Example 4: Well Child Visit (School-Age, Age 6)

Subjective: History from the mother and child. Well child visit; no acute concerns. Sofia is a 6-year-old girl who eats well, sleeps through the night, is active, and is doing well in kindergarten. No headaches, no vision or hearing concerns, no behavioral flags raised by parent or teacher. Up to date on immunizations. No chronic conditions, no daily medications. Family history notable for asthma.

Objective: T 36.9°C (98.4°F), HR 88, RR 20, BP 100/62, SpO₂ 99%, weight 20.4 kg (50th percentile), height 115 cm (50th percentile), BMI in the normal range. Well-appearing, interactive, age-appropriate. Normal head and neck, clear lungs, regular heart rhythm, soft abdomen, normal gait, no rashes. Vision and hearing screened, both normal.

Assessment: Healthy 6-year-old at a routine well child visit; growth and development on track.

Plan: Anticipatory guidance covering nutrition, physical activity, sleep, and screen time. Administered due immunizations per the AAP schedule after counseling. Standardized behavioral screening (PSC-17) completed by mother, scored, and reviewed together; no concerns identified. Return for the next scheduled well child visit in one year, or sooner if any concerns arise. Mother verbalized understanding.

Codes this note supports: Z00.129 with 99393 (established patient, ages 5 through 11). The immunizations add 90460/90461 with counseling documented, the vision and hearing screens add 99173 and 92551, and the behavioral screen adds 96127.

Pediatric SOAP Note Template

Copy this template and fill in each section: 

Patient: Name, date of birth, age, date of visit, who provided the history

Subjective

• Chief complaint (in the caregiver's or child's words)
• History of present illness: onset, duration, timing, severity, associated symptoms, home treatment
• Past medical and birth history, medications, allergies, immunization status
• Family, social, and developmental history
• Review of systems

Objective

• Vital signs and growth parameters with percentiles
• General appearance
• Focused physical exam by system
• In-office tests and results

Assessment

• Primary diagnosis (age-appropriate, specific, with severity)
• Secondary or chronic conditions
• Differential, if the diagnosis is unclear

Plan

• Diagnostics ordered
• Medications with weight-based dosing, route, frequency, and duration
• Non-drug care
• Caregiver education and red-flag signs
• Follow-up timeframe and referrals

How the SOAP Note Connects to Pediatric Coding

A pediatric SOAP note is both the clinical record and the documentation on which the claim rests. The note has to support the codes; otherwise, the codes are denied. Here's how the documentation drives the most common pediatric claims:

The pattern holds across pediatric coding. If the note doesn't say it, the claim can't bill it. Our pediatric coding guide covers these pairings in detail. 

Tips for Better Pediatric SOAP Notes

A few habits make pediatric notes clearer and safer:

• Name your source: always note who gave the history, since most pediatric subjective data comes from a caregiver.
• Be specific: "Afebrile, eating normally, playful, no respiratory distress" tells the next clinician more than "doing well."
• Always dose by weight: write mg/kg, route, frequency, and duration; "give acetaminophen" isn't enough for a child.
• Document the teaching: a line confirming the caregiver understood red flags protects the child and the record.
• Plot growth every visit: weight and height against percentiles, plus head circumference through about age 2, to catch problems that a single number hides.

Where Documentation and Billing Meet

Most pediatric practices know the frustration of a clean visit turning into a denied claim. The documentation was fine, but the coding was done later in a separate system, and something got lost in the handoff.

Develo closes that gap by keeping the note and the claim in one place. As the AI-native operating system for pediatrics, Develo unifies charting, billing, practice management, and family engagement in one system, so the coding logic already knows the rules this article covers:

• The Develo AI scribe for providers drafts the note within the visit workflow using pertinent patient and visit context, well beyond audio alone, all with no copy-and-paste or second window workflows. The intake scribe brings the same chart-aware, multilingual experience to the front of the visit, for nurses and medical assistants.
• Diagnoses and orders are automatically documented, so your Assessment note doesn’t need to rehash your diagnosis codes, and your Plan note doesn’t need to run through every single order. This includes screening and in-house test results, all saved in structured fields within your note.
• Growth charts plot from documented vitals, using the correct chart for the child's age and sex, with percentiles, Z-scores, and corrected-age plots for premature infants — so the Objective section is charted once, not recalculated.
• Immunizations are captured as structured data — inventory tracked by funding source with vaccine scanners, an automatic VFC-eligibility-to-funding-source check, and soonest-expiring lots prioritized — and administrations push to your state registry bi-directionally in real time.
• Screening scores flow straight from the note, so 96110 and 96127 bill only when the tool and score are documented.
• Same-day sick and well child visits get flagged for modifier 25, so the second service isn't dropped.
• Vaccine administration codes are flagged for 90460/90461 when a physician or other QHP has documented face-to-face counseling, and 90471–90474 when that requirement isn't met. 

Because charge capture is automated, the codes populate from the note itself and are ready the same day. That means fewer denials from documentation gaps and less time reconciling two systems that should have been one.

A pediatric SOAP note example is only as good as the claim it can carry. If your notes and your claims still live in separate systems, book a demo to see how Develo keeps them together. 

Frequently Asked Questions

How Is a Pediatric SOAP Note Different From an Adult One?

A pediatric SOAP note differs because the history comes from a caregiver, not the patient. It also adds growth parameters, developmental milestones, weight-based medication dosing, and immunization status, details that rarely appear in adult documentation.

What Goes in the Subjective Section of a Pediatric SOAP Note?

The subjective section contains the caregiver's report: chief complaint, history of present illness, past medical and birth history, medications, allergies, immunization status, and family, social, and developmental history. Always note who provided the history.

How Do You Document Growth in a Pediatric SOAP Note?

You document growth by recording weight and height with percentiles, plus head circumference through about age 2. Plot each against a growth chart so a value off the curve is visible and trackable across visits. 

How Does a SOAP Note Affect Pediatric Billing?

A SOAP note affects billing because documentation must support the codes. A developmental screen needs the tool and score recorded to bill CPT 96110, a same-day sick and well child visit needs modifier 25, and face-to-face counseling by a physician or other QHP must be documented to bill 90460/90461 rather than 90471–90474.