Posted: May 1st, 2025

WELLCHILD 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?