Pediatric SOAP Note Example: Acute Gastroenteritis with Mild Dehydration
A pediatric sick visit note: who gave the history, intake and urine output, hydration on exam, and weight-based dosing with the weight used.
By Francisco Sanchez, BSN, RN · ER nurse and FNP student · Updated October 2026
Setting: Outpatient pediatrics sick visitPatient: Fictional patient: 3-year-old boy, history from his mother
SSubjective
Chief complaint
"He's been throwing up and now he has diarrhea." Historian: mother.
HPI
1 day of vomiting (6 episodes, nonbloody, nonbilious), then watery diarrhea since this morning (5 episodes, no blood). Temperature 100.8 °F last night; acetaminophen given. Refusing solids; keeps down small sips of water but vomits after larger amounts. Urinated twice in the past 12 hours (usually every 3-4 hours). Tired but still playing. Two daycare classmates have had the same illness. No abdominal swelling, green vomit, headache, stiff neck, rash, travel or recent antibiotics.
Birth history
Term, uncomplicated.
Development
Meeting milestones for age.
Immunizations
Up to date per clinic record, including the rotavirus series.
PMH / meds / allergies
No medical history. Acetaminophen as above. No known drug allergies.
Social
Lives with parents and 6-year-old sister. Attends daycare.
OObjective
Vital signs
T 37.7 °C, HR 128 (mildly elevated for age), RR 24, BP 96/58, SpO2 99% on room air.
Growth
Weight 14.2 kg (14.8 kg at a well visit 3 weeks ago, about 4% loss). Height 96 cm, 50th percentile.
Exam
Tired but interactive and consolable; makes tears. Mucous membranes slightly dry (sticky). Capillary refill 2 seconds. Abdomen soft, nondistended, mild diffuse tenderness without guarding, hyperactive bowel sounds. Neck supple. No rash. Clinical Dehydration Scale 1 (some dehydration).
Data
Point-of-care glucose 88 mg/dL. In-clinic oral challenge: kept down 60 mL of oral rehydration solution over 30 minutes after ondansetron.
AAssessment
Diagnosis
Acute gastroenteritis, likely viral (daycare cluster), with mild dehydration (about 4% weight loss, Clinical Dehydration Scale 1). No signs of a surgical abdomen (no bilious vomiting, distension or focal tenderness) or bacterial colitis (no blood). Tolerating oral fluids after an antiemetic.
Growth / development
On track.
PPlan
Treatment
Ondansetron 0.15 mg/kg = 2 mg orally disintegrating tablet, one dose given in clinic (weight used: 14.2 kg). Oral rehydration solution: 5 mL every 1-2 minutes, increasing as tolerated; goal about 50 mL/kg (700 mL) over 4 hours, plus 10 mL/kg (about 140 mL) for each diarrheal stool. Resume his usual diet once rehydrated; avoid juice and sports drinks. No antidiarrheal medicines.
Anticipatory guidance
Handwashing; keep home from daycare until the diarrhea has stopped.
Caregiver education
Return or go to the ED for no urine in 8 hours, no tears, unusual sleepiness, green or bloody vomit, blood in the stool, severe belly pain, or vomiting that keeps him from drinking. Mother repeated these back.
Follow-up
Phone check tomorrow; clinic visit in 2 days if not improving. Next immunizations due at 4 years.
Fictional patient, written for learning. Follow your program's and facility's documentation standards.
Why this note works
It names the historian and documents intake and urine output, the core of a hydration history.
Dehydration is graded with numbers: percent weight loss and a validated scale.
The dose shows the mg/kg, the weight used and the final amount.
Caregiver education is specific enough to act on at 2 a.m.
What students often miss
Hydration status (intake, urine output)
The weight used for dosing
Caregiver education and when to return
Pediatrics SOAP note template
A growing patient with a caregiver as historian. Everything is compared with age-based norms.
SSubjective
Chief complaint
In the caregiver's words; name the historian.
HPI
Including feeding, intake, urine output, activity, sick contacts.
Birth history
For young children.
Development
Milestones for age.
Immunizations
Up to date? Per record or per parent.
PMH / meds / allergies
Social
Who lives at home, daycare/school, exposures.
OObjective
Vital signs
Interpret against age norms.
Growth
Weight, length/height, head circumference (under 2) with percentiles.
Exam
Including hydration and general appearance (playful, consolable).
Reading examples helps. Writing your own note and seeing exactly what you missed is what makes you better. SOAPy gives you a realistic case and checks your note section by section.