Documenting a 6-week check-up for a paediatric patient is a crucial task that requires accuracy and attention to detail. Proper documentation ensures continuity of care and provides critical information for future visits. In this guide, we'll explore how to effectively write and format clinical documentation using the SOAP (Subjective, Objective, Assessment, Plan) note structure, a widely used method in medical charting.

Subjective

The subjective section captures the patient's history and the caregiver's observations. For Baby Emma, this included details about her birth and early life:

Example: Baby Emma attended today with her mother for her 6-week check-up. Emma is a full-term infant born via spontaneous vaginal delivery with Apgar scores of 8 and 9. Her birth weight was 3.2 kg, length 50 cm, and head circumference 34 cm. She had mild jaundice at birth, which resolved without intervention. Her newborn screening tests were normal. Emma had no significant issues in the first few days of life.

Objective

The objective section includes measurable data such as vital signs and findings from the physical examination:

Example: Growth is on track with a weight of 4.5 kg (50th percentile), length 55 cm (50th percentile), and head size 37 cm (50th percentile). Full physical examination of Emma is normal. Her skin is clear with no rashes. The fontanelle is flat and soft, and the muscle tone is normal. The red reflex was present bilaterally. The pulses are strong and regular, and the heart sounds are normal. The chest is clear, the abdomen is soft and non-tender, the genitalia are normal, and the hips are stable. No other abnormalities were noted.

Assessment

This section provides a summary of the patient's progress and current condition:

Example: Overall, Emma's progress is excellent. She is exclusively breastfed, feeding every 2-3 hours for about 20 minutes each session. There are no feeding issues reported. Her bowel motions are regular and yellow. There have been no respiratory issues, and she is generally calm and alert. Emma has started to smile socially and follows objects with her eyes. She is thriving in terms of behavior and feeding.

Plan

The plan outlines the next steps for care, including any treatments, follow-up appointments, and patient education:

Example: Today we discussed normal infant development and feeding patterns. Mild jaundice – resolved, no further management needed. Provided a handout on infant sleep safety. Recommended resources for breastfeeding support. Advised to continue exclusive breastfeeding. Follow up in 6 weeks for the next routine check-up.

Incorporating AI medical scribes like Notis AI Medical Scribe can significantly enhance the efficiency and accuracy of paediatric documentation. Notis utilizes advanced voice-to-text technology to transcribe patient interactions and generate structured SOAP notes. This automation can reduce documentation time by up to 80%, allowing paediatricians to focus more on patient care.

Benefits for Paediatricians

The use of Notis AI Medical Scribe in paediatric settings offers several advantages:

• Time Efficiency: By saving up to 2 hours per day on documentation, paediatricians can increase their productivity and reduce burnout.

• Ease of Use: Operating through WhatsApp, Notis requires no additional software, making it easy to integrate into existing workflows.

• High Accuracy: With a transcription accuracy of 99%, Notis ensures reliable and precise documentation.

In conclusion, mastering the documentation of paediatric 6-week check-ups using structured templates ensures thorough and accurate patient records. The integration of AI medical scribes like Notis further enhances this process by streamlining documentation, ultimately improving patient care and allowing healthcare professionals to devote more time to their young patients.