Posted: May 1st, 2025

well child soap note

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?