Infant Soap Note Guide printable pdf download

Infant SOAP Note Guide:

Subjective:

Ex -- week (gender) infant born via (NSVD/C-Section secondary to--) to a G-P-, GBS (neg/pos/unknown) mother with

(neg/unknown/whatever) serologies who is currently on DOL #.

Pt is currently (breast/bottle) feeding and taking (duration/amount) every # hours. Pt had adequate urine output with # wet

diapers in the last 24 hours. Pt is (still passing meconium/pt is having bowel movements) # times per day.

(If you go to the room and examine baby with mom, always ask if she has questions or concerns) Mom has no current

questions or concerns. (if she does have questions.) All of mom’s questions were answered, her only concern is (blank) which

was discussed and mom reassured.

Objective:

Vitals: Temp : Pulse : Heart Rate : Respiratory Rate : Pulse Ox (always

include air source and O2 level NC/RA/etc : Weight (%change from birth weight)

General: Pt (sleeping/resting/feeding) comfortably in NAD

Skin: Free from lesions and rashes

Warm, dry with normal turgor.

HEENT: AFOSF, +RR B, Palate intact on inspection and palpation.

Ear canals patent B, no preaurricular pits. No craniofacial anomalies

CV: RRR (no) MRG Normal S1, S2. Femoral pulses 2+B

Resp: CTA B (no) WRR (no) Retractions, nasal flaring, grunting

Abd: Soft, NT, ND, (no) HSM, palpable masses. Umbilical stump dry

without signs of infection

GU:

Male: Normal Tanner Stage One Male. Testes descended, palpable B

Female: Normal Tanner Stage One Female

Rectal: Anus Patent

Ext: WWP, CR <2sec. Ortalini/Barlow negative B

Neuro: Moro, suck, root, grasp reflexes intact. Babinski sign present B.

Labs: Bilirubin (include hours of age at time of draw),

Blood Cultures: Pending/Final Negative x 24 hours

Assessment/Plan:

Ex -- week (gender) infant on DOL # - currently undergoing (evaluation for hyperbilirubinemia/septic work up/whatever)

include when the next bilirubin is, what cultures are pending- whatever is pertinent to the problem. If patient is on antibiotics include

the name and what day of treatment. Will discuss plan with pediatric care team.

OR if nothing is going on:

Ex -- week (gender) infant on DOL # -without current concerns. Continue feeds, and continue to monitor anticipate discharge

(48 hours for NSVD, 72 hours for C-Sections) Will discuss plan with pediatric care team.

Infant Soap Note Guide