SoapLab - Clinical Documentation Training

Pediatric Documentation Principles

Pediatric documentation requires attention to developmental stages, growth parameters, immunization status, and family dynamics. Children are not small adults — their presentations, normal values, and documentation needs differ significantly by age.

Age-Specific Vital Sign Norms

Always interpret vitals in context of age: **Heart Rate (normal ranges):** • Newborn: 100-160 • Infant: 100-150 • Toddler: 90-140 • Preschool: 80-120 • School age: 70-110 • Adolescent: 60-100 **Respiratory Rate:** • Newborn: 30-60 • Infant: 25-40 • Toddler: 20-30 • Child: 18-25 • Adolescent: 12-20 Document if values are normal or abnormal for age.

Growth Parameters

Document growth at every well visit:

•Weight (with percentile)
•Length/Height (with percentile)
•Head circumference (until age 2, with percentile)
•BMI (age 2+, with percentile)
•Growth velocity — crossing percentile lines is concerning
•Plot on growth chart and note trajectory

Developmental Assessment

Document developmental milestones by domain: • **Gross Motor**: Rolling, sitting, crawling, walking, running • **Fine Motor**: Grasping, pincer grip, drawing, writing • **Language**: Cooing, babbling, words, sentences • **Social**: Smiling, stranger anxiety, parallel play, cooperative play • **Cognitive**: Object permanence, problem-solving, school performance Note if milestones are met, delayed, or concerning. Use standardized screening tools (ASQ, M-CHAT) and document scores.

Pediatric History Considerations

Additional history elements for pediatrics:

•Birth history (gestational age, delivery, complications, NICU stay)
•Feeding history (breast/bottle, introduction of solids, current diet)
•Immunization status (up to date, delayed, refused)
•Developmental milestones
•School performance and behavior
•Family and social situation
•Childcare or school exposures
•Safety (car seats, helmets, water safety, firearms in home)

📋 Documenting the Pediatric Exam

**Example: 18-month well visit**

**Growth**: Wt 11.2 kg (50%), Ht 82 cm (55%), HC 47 cm (45%) — tracking along curve

**Development**:
• Gross motor: Walking independently, starting to run
• Fine motor: Stacking 3 blocks, scribbling
• Language: 10+ words, following simple commands
• Social: Parallel play, points to wants

**Physical Exam**:
• General: Active, interactive toddler in NAD
• HEENT: AF closed, TMs clear bilaterally, no dental caries
• CV: RRR, no murmur
• Resp: Clear bilaterally
• Abdomen: Soft, NT, no HSM
• GU: Normal external genitalia, testes descended bilaterally
• Skin: No rashes
• Neuro: Appropriate tone, gait steady

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Adolescent Confidentiality

Adolescent visits require special attention to confidentiality: • Interview adolescent alone for part of visit • Document sensitive topics (sexual activity, substance use, mental health) appropriately • Know your state's minor consent laws • Document what was discussed confidentially vs. with parent • HEADSS assessment: Home, Education, Activities, Drugs, Sexuality, Suicide/Safety

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Fever in Infants

Fever documentation in young infants is critical: • <28 days: Any fever (≥100.4°F/38°C) = full sepsis workup • 29-60 days: Low-risk criteria must be documented • Document: Temp, route, time, appearance, feeding, activity • Document: WBC, UA, blood culture results • Document: Disposition decision and reasoning

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Child Abuse Documentation

If abuse is suspected, document meticulously: • Exact quotes from child and caregiver (separately) • Detailed description of injuries (size, shape, color, location) • Photographs with ruler for scale (per protocol) • Developmental ability vs. stated mechanism • Caregiver behavior and affect • Document report to child protective services • Do NOT document 'suspected abuse' in chief complaint visible to family

Pediatric Documentation

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