Pediatricians often rely on structured clinical documentation to ensure high-quality patient care. The SOAP (Subjective, Objective, Assessment, Plan) format is widely used for its clarity and comprehensiveness. Let's break down how to correctly write and format a pediatrician's note using this method, with a practical example for each section.

Subjective Section

This section captures the patient's and family's narrative. Begin by noting the patient's name, date of service (DOS), date of birth (DOB), age, and gender. Include who accompanied the patient. For example:

PATIENT'S NAME: JAMES SMITH
DOS: 1 November 2024
DOB: 03/15/20
AGE: 4 years, 7 months, 17 days
SEX: Male
ACCOMPANIED by: Mother, Sarah Smith

In the narrative, detail the reason for the visit, symptoms, and any relevant history:

"James was brought in by his mother, Sarah Smith, for a routine check-up and concerns about a persistent cough. The cough started two weeks ago, is dry in nature, and occurs mostly at night. James denies any fever or shortness of breath. Past Medical History: Noted in chart. Medication History: Not currently on any medications. Allergies: NKA. Immunizations: Up-to-date. Growth and Development: Development appropriate for age. Diet and Nutrition: No loss of appetite, Eating well. Family History: No Changes."

Objective Section

This section includes measurable and observable data collected during the visit. Record growth parameters and vital signs, followed by findings from the physical examination.

Growth Parameters: Wt: 40 lbs, Ht: 42 inches
Vital Signs: Temperature: 98.6°F, Pulse: 90 bpm, Respiratory rate: 20 breaths/min

For the physical examination:

"General Appearance: Active, Alert, Pink, and Nontoxic. Eyes: Normal eyes, No redness. Nose: Mucus present in both nostrils. Ears: Normal TM with good LR. Throat: No redness or ulcers. Chest/Lungs: No distress, No wheezing or rales. Cardiovascular: Normal S1 and S2, No Murmur heard. Abdomen: Soft, Non tender, No HSM. Skin: No rashes. Musculoskeletal: Moving all Extremities well. CNS: Normal tone and reflexes."

Assessment and Plan

Provide a diagnosis and outline the plan for treatment. Use a numbered list for multiple issues:

"1. Persistent Cough - Investigations planned for Issue 1: Chest X-ray. Treatment planned for Issue 1: Prescribe cough syrup. 2. Routine Check-up - No additional investigations or treatments required."

Conclude with the physician's signature:

"-Signed: Dr. Emily Johnson MD"

Billing Information

Include relevant billing codes:

ICD-10 Codes: R05 - Cough
CPT Code: 99213 - Established patient office visit

Incorporating AI medical scribes like Notis can revolutionize pediatric documentation. Notis automates the transcription of patient interactions into structured SOAP notes, freeing pediatricians to focus more on patient care. By utilizing advanced voice-to-text technology, Notis ensures high accuracy and efficiency, saving healthcare providers significant time.

Notis operates seamlessly through popular platforms like WhatsApp, requiring no additional software learning. With features such as document and image analysis, and multilingual support, it caters to diverse patient populations, making it an invaluable tool in pediatric practices. The integration of Notis allows pediatricians to maintain thorough and precise patient documentation, improving the overall quality of care.