Pediatric documentation has moving parts that adult-focused templates miss: growth tracking, developmental screening, immunization schedules, and caregiver-reported history. These templates are structured for the visit types you see most.
Disclaimer: This template is for documentation structure only. Practices should adapt it to their clinical, legal, and organizational requirements. Pediatric documentation may be subject to additional consent, confidentiality, and reporting requirements depending on your jurisdiction.
Well-child visit template
SUBJECTIVE
Visit type: Well-child visit — [Age: e.g., 12-month, 4-year]
Informant: [Parent/guardian/caregiver name and relationship]
Parent/caregiver concerns: [Any concerns raised about development, behavior, feeding, sleep]
Interval history: [Illnesses, injuries, ER visits, hospitalizations since last visit]
Nutrition:
- Feeding type: [Breast milk, formula, table foods, diet description]
- Appetite/intake: [Any concerns]
Sleep: [Hours per night, sleep environment, concerns]
Elimination: [Stool/urinary patterns — especially relevant for infants/toddlers]
Behavior/development (parent-reported):
- Gross motor: [e.g., walking, running, climbing]
- Fine motor: [e.g., pincer grasp, drawing, writing]
- Language: [e.g., words, sentences, following commands]
- Social/emotional: [e.g., interaction with peers, separation anxiety]
Review of systems: [Age-appropriate ROS]
Medications: [Current medications and supplements, including vitamins]
Allergies: [List with reaction type]
OBJECTIVE
Vital signs: HR ___ | RR ___ | Temp ___ | BP ___ (if age-appropriate)
Growth parameters:
- Weight: ___ kg (___ percentile)
- Length/Height: ___ cm (___ percentile)
- Head circumference (if under 3 years): ___ cm (___ percentile)
- BMI (if ≥2 years): ___ (___ percentile)
Physical exam:
- General: [Appearance, activity level, interaction]
- HEENT: [Fontanelles (if infant), TMs, oropharynx, dentition]
- Cardiovascular:
- Pulmonary:
- Abdomen:
- Genitourinary: [Tanner staging if relevant]
- Musculoskeletal: [Hip exam in infants, scoliosis screening in adolescents]
- Neurological: [Tone, reflexes, gait as age-appropriate]
- Skin:
Developmental screening:
- Tool used: [e.g., ASQ-3, M-CHAT-R/F, PHQ-A, Edinburgh (postpartum caregiver)]
- Results: [Score and interpretation]
- Gross motor: [Pass / Concern / Refer]
- Fine motor: [Pass / Concern / Refer]
- Language: [Pass / Concern / Refer]
- Social-emotional: [Pass / Concern / Refer]
Vision screening: [Method and result]
Hearing screening: [Method and result]
ASSESSMENT
1. Well-child visit — [Age], [overall assessment: developing appropriately / concerns identified]
2. [Any identified concern — e.g., speech delay, elevated BMI, eczema]
PLAN
1. Well-child care:
- Immunizations administered: [List vaccines given today]
- Immunizations deferred: [List with reason]
- Screenings ordered: [Lead level, hemoglobin, etc.]
- Anticipatory guidance provided:
- Safety: [Car seat, water safety, helmet, poison prevention — age-specific]
- Nutrition: [Feeding recommendations for age]
- Development: [Activities to encourage next milestones]
- Sleep: [Safe sleep / sleep hygiene recommendations]
2. [Concern #2]:
- [Referral, monitoring plan, or treatment]
Consent documented: [Who consented, verbal/written]
Follow-up: [Next well-child visit timing per schedule]
Acute pediatric visit template
SUBJECTIVE
Chief complaint: [As reported by parent/caregiver and child if age-appropriate]
Informant: [Parent/guardian/caregiver]
History of present illness:
- Onset:
- Duration:
- Severity:
- Associated symptoms: [Fever, vomiting, rash, activity level changes]
- Oral intake/hydration: [Amount, last wet diaper or void]
- Aggravating/relieving factors:
- Treatments tried at home:
- Sick contacts / daycare exposure:
Review of systems: [Focused — pertinent positives and negatives]
Medications: [Current medications, recent antibiotics, OTC medications given]
Allergies: [List with reaction type]
Immunization status: [Up to date / behind — relevant if infectious concern]
OBJECTIVE
Vital signs: HR ___ | RR ___ | Temp ___ (method) | SpO2 ___ | Weight ___ kg
General: [Activity level, consolability, interaction, hydration status]
Physical exam: [Focused, relevant systems]
- [e.g., TMs for ear pain, oropharynx for sore throat, lungs for cough]
Point-of-care testing: [Strep, RSV, flu, UA, etc.]
ASSESSMENT
1. [Diagnosis or clinical impression] — [supporting clinical reasoning]
Differential: [If uncertain — e.g., viral URI vs. early AOM]
PLAN
1. [Diagnosis]:
- Treatment: [Medication with weight-based dosing, route, duration]
- Supportive care: [Fluids, rest, fever management]
- Caregiver education:
- Expected course: [e.g., "symptoms typically improve in 3-5 days"]
- Return precautions: [Specific warning signs — e.g., "return if unable to keep fluids down, fever >X days, difficulty breathing"]
- Follow-up: [Specific timing or conditional return]
Consent documented: [Who consented to treatment]
Key documentation considerations for pediatrics
Growth tracking
Growth parameters are central to pediatric care. Document actual measurements and percentiles at every visit. For children under 3, head circumference is standard. For children 2 and older, BMI percentile helps identify overweight and underweight. Note the growth chart standard used (WHO for under 2, CDC for 2–20) if your organization requires it.
Developmental screening
Use validated, age-appropriate screening tools and document both the tool name and the result. If a screen flags a concern, document the specific domain affected and the plan — whether that is a referral for formal evaluation, a rescreen at the next visit, or caregiver education.
Immunization documentation
Record each vaccine administered (product name, lot number, site, and route) along with any vaccines that were due but deferred, and the reason for deferral. Ensure your documentation aligns with your state immunization registry requirements.
Consent and confidentiality
Document who provided consent for the visit and any procedures. For adolescent patients, be aware of your jurisdiction's rules around confidential care for reproductive health, mental health, and substance use. Separate confidential information per your organization's policy.
Weight-based dosing
Always document the child's weight used for dosing calculations. This gives the next clinician — or the pharmacist — a clear reference point and supports medication safety.
Specialty resources
For a general-purpose starting point, see the base SOAP note template. Learn more about how Dictum supports pediatric documentation with age-aware note generation. You can also set up AI-generated SOAP notes that include developmental and immunization sections by default.
Frequently asked questions
What should a well-child visit note include? A well-child visit note should cover growth parameters, developmental milestone screening, immunization status, nutrition and safety counseling, and an age-appropriate physical exam. Screening tool results (e.g., ASQ, M-CHAT, PHQ-A) should also be documented.
How do I document developmental milestones in a SOAP note? Include a dedicated developmental screening section in the Objective area. Document the screening tool used, the results, and whether the child met expected milestones for their age in gross motor, fine motor, language, and social-emotional domains.
Who provides consent for pediatric visits? Consent requirements vary by jurisdiction and patient age. Generally, a parent or legal guardian provides consent for minors. Some jurisdictions allow adolescents to consent to specific services such as reproductive health or mental health care. Document who provided consent for the visit.
How do I handle confidential adolescent visits? Many jurisdictions allow confidential care for adolescents in specific areas. Document the confidential portion of the visit separately per your organization's policy, and ensure the shared portion of the note does not include information the adolescent disclosed in confidence.
Can AI-generated notes work for pediatrics? Yes. Dictum can draft pediatric SOAP notes from encounters or dictation. The clinician reviews the note to confirm developmental assessments, immunization records, and clinical recommendations are accurate before signing.
Less charting, more time with your patients and their families. Try Dictum free — pediatric-aware AI SOAP notes drafted from your encounters, ready for review.