Pediatric SOAP Notes

If you’re working in the field of pediatric behavioral health and looking for information on pediatric SOAP notes, including pediatric SOAP note examples, you’re in the right place.

Special considerations must be made for the pediatric clients in our practices. 

Children and adolescent clients bring unique benefits and challenges to therapy due to their developmental levels. 

In addition to adapting our treatment approaches for pediatric clients, we must also change the way we document their progress.

Reasons pediatric behavioral health care requires different documentation

There are several reasons you will want to document your pediatric clients’ progress differently than your adult clients.

Children and adolescents tend to be poor historians 

Children’s understanding of time is obscure, so what happened one month ago may be relayed to us as happening “yesterday.” 

Adolescents tend to give us vague, short descriptions, like “I’ve been sad for a while” or “Yeah, I’ve had a panic attack.” 

These responses don’t help much when it comes to documentation; instead, we’re left deciphering what exactly these answers mean. 

Children have a limited understanding of symptom severity 

For example, the fact that a child has wet their bed seven nights in a row is likely insignificant to them, and they probably won’t volunteer such information during the session. 

Adolescents usually keep quiet about anything that could damage their self-image. They often withhold key details, like having thoughts of self-harm or suicide, in attempts to minimize or deny psychopathology. 

Thus, good clinical documentation should include feedback from the child’s or adolescent’s parents or guardians, whether given during a check-in at their appointment or a separate, parent-only session. 

This verification lowers our risk of misdiagnosing children and adolescents, and providing improper treatment.

Children and adolescents usually talk less during sessions than adult clients 

Limited oral communication can leave us puzzled when we start our progress notes. 

To provide accurate documentation, we must pay close attention to our younger clients’ nonverbal cues. 

Facial expressions and body language are excellent points to record because they indicate our clients’ underlying emotions. 

We can document how a child “smirked as they put the final block on top of their tower,” which represents a confident attitude. We can note how a teenager’s “shoulders slumped as they idly tossed miniatures into the sand tray,” which shows disinterest or fatigue. 

Legal guardians are mandated to participate in the therapy process 

Unless an adult client signs a release of information, or is obliged to turn over medical records to comply with a legal l subpoena or insurance audit, no one else has access to their records. 

This isn’t the case with pediatric clients, though, whose legal guardians must participate in the therapy process. 

Their involvement includes a right to view our client’s intake assessment, treatment plan and updates, and progress notes. With custody cases, we must be especially mindful regarding what we document and how it’s worded. 

Documentation should sufficiently explain why we’re using certain interventions with children and adolescents 

To non-clinicians, the terms “art therapy,” “play therapy,” and “sand tray therapy” can seem nonsensical.

Since the legal guardians of your minor clients likely don’t have clinical backgrounds, but often have to participate in treatment, it’s important to offer an explanation in pediatric SOAP notes. 

Similarly, insurance companies may be curious about why these interactive components are needed. 

A clear reasoning for our approaches must be documented, and can be done so using the SOAP note template.

Overview and adaptation for pediatric SOAP notes

SOAP notes for mental health contain four categories, one for each letter in the acronym: Subjective, Objective, Assessment, and Plan. 

These sections help us document and conceptualize clients’ progress in a succinct format. 

Subjective

The Subjective category is reserved for client-reported symptoms. 

Record a client’s quotes in this section. 

Pay close attention to the physical symptoms reported by children and adolescents. They have a smaller emotional vocabulary than adults, and are more likely to tell us how they’re feeling using somatic complaints—like “my stomach hurts” instead of “I feel anxious.” 

Information gleaned from parent check-ins should also be noted here. 

Objective

The Objective category is where we note our observations. 

Document your client’s body language and facial expressions here. 

Keep your comments objective and simple, and don’t offer suggestions or assumptions. 

There are many helpful details to record if you’re using an expressive therapy, such as play or art therapy. These therapeutic modalities are popular in pediatric behavioral health for this reason precisely—they allow the therapist to objectively observe the client’s non-verbal cues. 

Note what items your client used and the manner in which they used them. For example, “client quickly grabbed a box of Legos and dumped blocks loudly onto the floor” or “client slowly selected art materials, then quietly painted canvas.” 

Assessment 

The Assessment category is a combination of the client’s reports and our clinical observations. 

Reflect on the session, as well as your client’s overall progress, as you record this section of your pediatric SOAP notes. 

Document how the things you heard and saw during the appointment relate to your client’s accomplishment of their treatment goals. 

If the client and their parents gave conflicting reports or presentations, note the discrepancies. For example, “mother reported that the client has been spending more time with friends; however, the client stated they felt lonely this week and don’t have friends.”.

Plan

The Plan category is where you record action steps. 

Decide what you need going forward to best help your client, and outline it here. 

For children and adolescents, this may mean scheduling more family sessions to help the system as a whole. 

It may also mean the transition into a different type of therapy—like switching to trauma-focused or expressive-based modalities—if your current approaches are ineffective.

Sample pediatric SOAP note

Included below is a sample pediatric behavioral health SOAP note. 

In this example, the client is a 12-year-old male who’s had several sessions of art therapy to address generalized anxiety. 

Pediatric Subjective section examples 

• Client reported that he “couldn’t breathe” yesterday when he started taking a test at school. Client said his “stomach felt funny” and he asked his teacher to use the bathroom. 

• Client stated “this always happens” when he has to take end-of-year tests. 

• Client mentioned trouble sleeping this week in the days leading up to the “big test.” 

• At the end of the appointment, mother confirmed that the client had “restless sleep” over the past several nights, and complained of daily stomach aches this week before school. 

• Mother explained that the client had the opportunity to attend tutoring for the past two weeks, but declined to attend. 

• Mother also reported that the client has continued to avoid peers, by rejecting their invitations for after-school activities. 

Pediatric Objective section examples 

• Client avoided eye contact while talking about school and preoccupied himself with artwork. 

• Client interrupted the therapist’s question about school to ask if he could use the bathroom. 

• After the therapist agreed to excuse him to use the bathroom, the client left the room and returned after 10 minutes. 

• Client ignored the therapist upon returning  to the art room and sat with his back to the therapist to continue his artwork. 
• Client gave minimal answers to the therapist’s attempts to engage in conversation.

Pediatric Assessment section examples

• Client’s self-report of panicking when presented with an academic test, and his difficulty sleeping over the past week leading up to the test, confirms his continued struggle with performance anxiety. 

• Client described avoidance behavior by asking his teacher to use the bathroom upon starting the test, and demonstrated the same behavior during today’s session when he left for an extended period of time to use the bathroom. 

• Client showed disinterest in processing his performance anxiety and low-resiliency, as evidenced by his short and distracted responses to the therapist’s prompts. 

• Mother’s reports verify that the client still feels anxious about his academic performance and tries to avoid it through somatic complaints. 

• Mother’s comments confirm that the client persists in his social anxiety, as demonstrated by his withdrawal from peers. 
• Client continues to meet criteria for generalized anxiety disorder, with his symptoms primarily manifested in academic and social settings. 

Pediatric Plan section examples

• Schedule a parent-only appointment with the client’s mother to discuss healthy interventions to use with him at home. 

• Review grounding techniques with the mother and encourage her to use them with the client twice daily—before he leaves for school and after he arrives home.

• Transition the client to sand tray therapy due to his continued resistance to processing his sources of anxiety.   

Closing summary

Adopting a different attitude toward child and adolescent clients includes a different way of note-taking. 

Pediatric SOAP notes require therapists to consider additional factors when drafting—which may not be relevant when writing SOAP notes for adults.   

As we respect their differences in therapy, we can better recognize and document our pediatric clients’ progress. 

This approach helps us to keep more useful and informative records as we continue working with children and adolescents. 

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