Use the SOAP system to lay out your initial notes.
- Start with the history (story or what is said):
- The reason for referral should be noted together with the child’s age and gender. It is important to begin with the presenting complaints and the detailed history relating to each of them. This will form the present history.
- Any important points from the past history should be recorded.
- Any outstanding immunisations must be recorded.
- Important facts from the social history should be noted.
- Each section of the history (present, past, immunisation and social history) is given a separate heading to make it easier to read.
- Important positive and negative aspects of the special questions are usually written under a separate Special Questions heading. This completes the history section of the notes.
- The physical examination follows next. This usually is written under the following headings:
- Weight (and sometimes head circumference and length or height)
- The general appearance of the child (including nutritional state and hydration)
- Specific general signs (such as pallor, cyanosis, jaundice and oedema)
- Important positive or negative signs from each body part (e.g. head) or organ system (e.g. cardiovascular system)
- List special investigations asked for, note the date of the investigation and record any results available.
- Make an assessment by drawing up a problem list with diagnoses where possible.
- Write a plan of action for each problem.
All notes must clearly state the date and your name.