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Well-child SOAP Note Format Demographic Data · Age, and gender (must be HIPAA compliant)

June 10, 2025

Well-child SOAP Note Format

Demographic Data

· Age, and gender (must be HIPAA compliant)

Subjective

· ___-day/week old infant/child accompanied by ___________ and here for a routine well-child/baby check (and vaccines). Any parental concerns/ questions today?

· Interval Events/History:

· Nutrition:

· Elimination:

· Sleep:

· Medications:

· Allergies:

· Past Medical

· Pregnancy and delivery?

· Surgeries, hospitalizations, or serious illnesses to date?

· Immunizations?

· Development: (describe as applicable to age)

· Gross motor:

· Fine motor:

· Cognitive:

· Social/Emotional:

· Communication:

· Social History:

· Smoking in the home?

· Family life/structure/dynamics? Primary caregivers?

· Stressors?

· Family History:

Objective
(Should be a thorough head to toe assessment)

· Vital Signs/growth measurements (weight, length, head circumference, BMI, BP, HR, etc. if applicable)

· Physical findings listed by body systems, not paragraph form.

· Highlight abnormal findings

· Growth Chart Percentages: if applicable

· Labs/Studies: if applicable

Assessment

· Well-child visit ICD10 code(s)

Plan

· Vaccines today:

· Anticipatory guidance (discussed or covered in the visit)?

· Health Maintenance

· Return precautions?

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