Thursday, December 16, 2010

SOAP Notes For The Pediatric Patient: A How-To Guide

The original post on how to write a SOAP note for a patient was intended to be a definitive post on how to write this daily note that every med student / intern / resident and even attending comes to know and love (haha, or hate). However, after receiving feedback on the initial post and going through more rotations myself, the need for specialty-specific SOAP note templates became apparent. Following the recent on post on how to write a SOAP note for a surgical patient, this post describes the basic format and outline of the note and what some basic options are for what exactly to describe in the note. For example, the mnemonic OLD CHARTS helps remind you of what to put for the history of a particular symptom, such as "cough."

Once again, the basic format for a note is the SOAP note. SOAP stands for:
Subjective: any information you receive from the patient (history of present illness, past medical history, etc)
Objective: any data, whether in the form of a physical finding during your exam, or lab results
Assessment: diagnoses derived from the history and objective data
Plan: what you intend to do about the diagnoses from your assessment
For pediatricians though, many other concerns come into play, especially depending on the precise age of the patient. The younger they are, the more this matters. Think about it: a 17 day old's note clearly will contain different pertinent information as compared to the SOAP note for an adolescent 17 year old! A medical student should share in this contextual-based note in order to excel on the service. The ideal student on pediatrics should be able to document the patient's complaints and exam findings succinctly, assess them, make a plan for treatment of any issues found, and anticipate and prevent other common problems. 

The pediatric note starts like any other note. Date and time the note, then write down your position and title of the document, such as "MS3 Purple Pediatrics Progress Note".  Next, note the day of admission. If the patient was previously started on antibiotics, it is also helpful to denote what day of antibiotics they are on. 

For the SUBJECTIVE portion of the note, you want to include any complaints the patient might have. If the patient is recovering normally, be sure to ask about regular body functions, such as voiding, passing flatus (gas), tolerating PO (oral food), and ambulation (walking) and mention these briefly in your note. 
For any symptom like a cough or rash, use the OLDCHARTS mnemonic from "How To Write a SOAP Note" to further describe the complaint.

A few age-specific notes: for pre-verbal patients (neonates up to two year olds), do not overlook the subjective! Even though the patient cannot express themselves like an older child or adult, you can still glean information from the parents and nursing staff as to whether the child has been fussy or sleepier than expected or any other change in their behavior. For adolescents, keep the HEADSS assessment in the back of your mind. HEADSS stands for:
Home - Inquire about the patient's support system at his place of residence and actual living environment. 
Education (or Employment) / Eating - Ask about the child's educational performance. If employed, assess how they find their job and their job performance. E can also cover eating; specifically ask about how many meals the child ingests and where their calories come from. Also consider any weight changes.
Activities - Discuss what the patient enjoys doing and who they share these pursuits with.
Drugs (including alcohol and tobacco) - Ask directly about drug use, both licit (caffeine) and illicit (alcohol, marijuana, cocaine, etc). If using, ask about frequency, amount, and other characteristics.
Sex - Inquire if patient is sexually active. If so, discuss protection, STD prevention, and who they feel comfortable discussing sexual issues with.
Suicidality (including general mood assessment) - Assess the patient's mood and whether they are a risk to themselves or others.
You may consider an additional S, Strengths, to end the discussion on a positive note.

For the OBJECTIVE portion, the note should include the vital signs, I/Os including from drains, and physical exam findings. The vital signs should note the maximum temperature and at what time it occurred. If above 38 deg C or 100.4 deg F, note what was done to remedy the fever (if anything). This number is very specific in pediatric medicine as opposed to adult medicine. A temperature of 100.5 F is a fever, period. 

For the I/Os, note the rate of IVF administration and the fluid being administered. For neonates, this is very very important. Make sure to note not only the total ins and outs, but also the caloric intake in kcal/kg/day, the fluid intake rate at cc/kg/day, and the urine output in cc/kg/hr. Because of the rapid changes right after birth as the baby adjusts to life outside the womb, sudden changes in these values can suggest very severe problems, so it is essential to pay close attention to these values. 

The physical exam should include the head-ears-eyes-nose-throat (HEENT), pulmonary, cardiovascular, abdominal, wound, and extremity exams. A normal exam may read:
GEN - A&O x 3 (alert and oriented to person, place, time), activity level  
HEAD - NC/AT (normocephalic / atraumatic)  
EYES - RR+, EOMI (red reflex present, extraocular movements intact)  
EARS - TMs intact (tympanic membranes intact) 
NOSE - nares clear 
THROAT - OP clear (oropharynx clear) 
NECK - supple, no LAD (no lymphadenopathy) 
PULM - CTAB, no C/W/R (clear to auscultation bilaterally, no crackles, wheezes, or rhonchi) 
CV - RRR, no M/R/G, 2+ pulses (regular rate and rhythm, no murmurs, rubs, or gallops, good pulses) 
ABD - +BS, S/NT/ND (positive bowel sounds, soft, nontender, nondistended)
EXT - no c/c/e (no clubbing, cyanosis, or edema) 
SKIN - no bruising, no rash 
Always have a concern for child abuse in the back of your mind, especially if you encounter physical findings that do not match the mechanism of injury given in the history. Any pediatric review book can go over typical physical and radiographic findings in cases of abuse. However, also be aware of physical exam differences in pediatrics, especially between the ages of zero to two, as certain body parts are still developing / regressing (ex. closure of fontanelles, changing reflexes, ossification of cartilage)

For the ASSESSMENT portion, the note should give a one sentence summary of the patient and why they are in the hospital. For newborns, include details about their birth, especially if they had a complicated pregnancy or delivery. For patients with complications, consider adding a clause or another sentence describing the reason for an extended hospital stay. 

For the PLAN portion, the note should address any issues raised in the subjective, objective, or assessment sections. Address each issue specifically. If unsure, refer to a book like Nelson Essentials of Pediatrics for management. Another good resource would be First Aid for the Pediatrics Clerkship. For every patient, include a plan for their fluids/diet and disposition (how are they getting home). 

If you follow this basic structure, you should do just fine as far as SOAP note writing on pediatrics goes. If you are in a general pediatrics ward, this should be sufficient. However, if you are on a team that addresses one particular age group, especially neonates and adolescents, take the time to look up more detailed SOAP note structures in your textbooks and review books (such as First Aid or Case Files For Pediatrics). These and other books for the pediatrics shelf exam will help guide you in developing clinical acumen when it comes to treating neonates, children, and adolescents. The more questions you ask, the more your star will shine, and more importantly, the better care you will take of *your* patient!

Updated 2015-12-20

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