Compliance and documentation
How pediatric SOAP notes are different (with examples)
Pediatric clients have different considerations, which further complicates documentation. Let’s discuss the differences to make the process easier.
May 16, 2025 • Updated on August 29, 2025
7 min read
You wouldn’t approach a therapy session with a child in exactly the same way you’d approach an adult appointment — so why should your documentation be one-size-fits-all? Writing a good pediatric progress note takes a different technique than writing one for an adult client.
That said, you don’t have to reinvent the wheel. Formats that you already know and use for standard progress notes can be easily adapted for younger clients.
Take SOAP notes, for example. You can use the same fundamental approach to write a SOAP note for a pediatric client, while making some key modifications to better fit your young patient. Here’s how.
How pediatric SOAP notes are different from regular SOAP notes
As the acronym implies, there are four main components of a SOAP note: subjective, objective, assessment, and plan.
A pediatric SOAP note still contains these four major sections — but the content of each section may be different from what you’d write for an adult client, since young clients have different communication styles and may benefit from different therapeutic approaches. Pediatric SOAP notes also often include information provided by your patient’s parents, caregivers, teachers, or other healthcare providers, since adults are typically involved in mental healthcare for a minor.
Subjective
This section is used to describe the client’s self-reported symptoms and status, supported by direct quotes where possible. It may be more challenging to fill out this section when working with a child or adolescent, as they may not have the words or self-awareness to describe their mental health in detail. In this part of the note, you may need to rely on other sources of information, like caregiver assessments of the child or the client’s description of physical symptoms that may be related to mental health issues, such as stomach aches or headaches. It can be helpful to ask: What does the client believe or feel is happening?
Objective
You’ll list your observations about your client in this section, potentially assessing their appearance, affect, body language, behavior, speech, developmental milestones, and more. If you use play, music, art, or movement therapy in your pediatric sessions, you can take note of how the child responds to those activities, too. Aim to keep your notes objective and rooted in specific examples.
Assessment
The content in the first two sections of your SOAP note should inform this one. Drawing on the client’s self-reports and your observations of them, you’ll justify their diagnosis, progress, risk assessment, and treatment plan. You can also take into account reports from caregivers or other adults when making your assessment.
Plan
The fourth and final section of a SOAP note is forward-looking. Here, you can describe goals for future treatment; areas on which to focus or interventions to try in upcoming sessions; and any necessary adjustments to your client’s treatment plan. When working with a child, this section may also address practical behavioral interventions or ways to involve the entire family in future care.
Considerations when writing pediatric SOAP notes
Before you sit down to write a pediatric SOAP note, it’s wise to consider how you’ll approach the task differently than you would with an adult client — otherwise, you may find yourself staring down a blank page when it’s time to document your session. Keep these considerations in mind as you go into pediatric sessions, so you’re ready to prepare your documentation when the time comes.
Gather information from caregivers and teachers.
When treating an adult, their words and behavior in sessions are typically all you have to go on. That’s not the case with pediatric patients, whose caregivers, teachers, or other healthcare providers may be involved in the therapy process. Speaking with the adults in your client’s life can provide valuable information that informs your care and fleshes out your SOAP notes. For example, if your pediatric client struggles to describe their symptoms, you may get a fuller picture by speaking with their caregivers. Or, your client’s caregivers may provide you with information that contradicts what the client says in sessions. That’s valuable to consider, too.
Write your notes with caregivers in mind.
Your client’s caregivers won’t only contribute to SOAP notes; they may read them, too. For that reason, it’s especially important to be clear, professional, and objective in your notes. You may also want to refrain from using unnecessary jargon or take a bit more time to explain why you chose to use certain interventions and how they contributed to your client’s care. This extra explanation can also come in handy when dealing with insurance claims.
Remember to look for alternate sources of information.
A child or adolescent may be unable or unwilling to describe their mental health status in words, which can make the documentation process tricky. If that’s the case, you may need to rely more heavily on observations about their behavior, developmental progress, body language, and facial expressions, especially when writing the “objective” section of your note. Remember to pay extra attention to these sources of information during your session.
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Pediatric SOAP note examples for common situations
Below, find two examples of pediatric SOAP notes for common therapeutic situations.
Patient: Jason M.
Age: 9 years
Date: April 21, 2025
Therapist: Jane Doe, LCSW
Diagnosis: Attention-Deficit/Hyperactivity Disorder, Combined Presentation (F90.2)
Type of Session: Individual therapy (in-office)
S – Subjective:
Jason arrived to the session on time with his mother. He appeared energetic and eager to engage. His mother reported that he had a "rough start to the week," with two incidents at school involving interrupting during class and one instance of forgetting his homework. However, she noted that Jason responded well to redirection and completed his assignments later in the day. Jason shared that he "gets bored fast" in class and "wants to be able to stop talking but sometimes can't." He expressed frustration over getting in trouble for things he "can't control."
O – Objective:
Jason was alert and oriented. He demonstrated normal speech and language for his age. During the session, he exhibited fidgeting and difficulty sitting still for extended periods, frequently shifting in his chair. He required prompts to stay on task but responded well to visual cues and positive reinforcement. He engaged intentionally in a structured game designed to promote impulse control, showing improvement from the previous session in his ability to wait his turn and follow multi-step directions.
A – Assessment:
Jason continues to present with symptoms consistent with ADHD, including impulsivity, hyperactivity, and inattention. He is making incremental progress in self-awareness and behavioral regulation during sessions. His mother reports he is redirectable and having success with completing assignments in school. He benefits from structured activities and consistent behavioral strategies. His insight into his challenges is increasing, and he is beginning to articulate his frustrations and needs more effectively.
P – Plan:
- Continue weekly individual therapy sessions focusing on impulse control, emotional regulation, and attention-building strategies.
- Implement a token reward system both at home and in therapy to reinforce desired behaviors.
- Coordinate with school counselor to support classroom strategies and accommodations.
- Introduce a mindfulness activity next session to support focus and calmness.
- Follow-up with pediatrician regarding recent behavior concerns and medication management.
Client Name: Emma R.
Age: 12 years
Date of Session: 04/21/2025
Therapist: Jane Doe, LCSW
Diagnosis: Unspecified Anxiety Disorder (F41.9)
Type of Session: Individual therapy (telehealth)
S – Subjective
Emma didn’t make eye contact and appeared slightly nervous at the beginning of the session but she assumed a more relaxed posture as the session progressed. She reported feeling “a little scared” before her recent spelling test and described “butterflies” in her stomach. She said, “Sometimes I think I’ll mess up and everyone will laugh.” Emma shared that her mother helped her practice calming breaths, which “helped a little.” Her mother reported that Emma had fewer bedtime worries this week and slept through the night 4 out of 7 nights.
O – Objective
Emma was appropriately dressed and appeared well-nourished and rested. She maintained good eye contact throughout the session and engaged in structured activities with minimal redirection. She was able to identify and label three different emotions using visual aids and rated her anxiety on a 1–10 scale, identifying a “5” when discussing tests and a “2” when talking about playdates.
A – Assessment
Emma is making gradual progress in identifying and verbalizing her anxiety-related thoughts and physical symptoms. She reports she is responding well to coping skills such as deep breathing and the “worry jar” technique introduced in a previous session. Continued parental support appears beneficial. Anxiety symptoms remain present but are manageable with support and intervention, as evidenced by lower anxiety ratings.
P – Plan
- Continue individual CBT-based therapy sessions weekly.
- Introduce cognitive restructuring activity next session using “real vs. imagined worries.”
- Encourage continued use of deep breathing and worry jar at home.
- Check in with parent via email mid-week to monitor bedtime routines.
- Reassess anxiety symptom severity in 2 weeks with a child-appropriate scale.
Answering your FAQs
Still have questions about pediatric SOAP notes? Here are answers to some common provider questions.
What are common mistakes to avoid when writing pediatric SOAP notes?
As with adult SOAP notes, you should try to balance the need for thorough documentation with brevity and privacy. That means including everything needed for insurance claims — and to adequately track patient progress — without writing too much or including details that are not relevant to treatment. Remember that your client’s caregivers may read the notes, so keep your tone objective and clinical and do not include overly intimate or personal details unless they are necessary to care.
Why is social history more important in pediatric SOAP notes?
Understanding your client’s social history gives you a fuller picture of their overall well-being, health, and risk factors. Particularly when working with young clients who may not have as many verbal tools for self-expression, it’s important to gather a comprehensive social history by speaking with the client and the adults in their life.
What role do parents and caregivers play in pediatric SOAP notes?
Parents and caregivers are crucial to writing good pediatric SOAP notes, as they can shed light on your client’s symptoms, behavior outside of sessions, and overall progress. Aim to check in with caregivers either at your client’s regular appointments or during separate adults-only sessions.
Focus on caring for your pediatric clients, let Headway handle the rest
You should be able to focus on providing care for your pediatric clients, without getting caught up in administrative tasks — and with Headway, you can. Headway’s free, all-in-one platform includes assets like documentation templates and billing tools, so you can focus more of your attention on your clients, whatever their ages.
This content is for general informational and educational purposes only and does not constitute clinical, legal, financial, or professional advice. All decisions should be made at the discretion of the individual or organization, in consultation with qualified clinical, legal, or other appropriate professionals.
© 2025 Therapymatch, Inc. dba Headway. All rights reserved. No part of this publication may be reproduced without permission.
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