SOAP Note Example for Acute Otitis Media in a Child

What belongs in the Subjective for pediatric AOM?

The Subjective should make the diagnosis defensible and capture the parent's narrative in their own words. AOM is largely a clinical diagnosis, so timing and associated symptoms matter.

• Onset and ear-specific symptoms: ear pain, tugging, irritability, decreased hearing, otorrhea.
• Systemic context: fever (with measured temp if known), reduced feeding or sleep, recent or concurrent viral URI.
• Red-flag review: neck stiffness, severe headache, swelling or redness behind the ear, lethargy.
• History that changes management: allergies, recurrent AOM, tympanostomy tubes, immunization status, prior antibiotics.

What otoscopic findings should the Objective capture?

The Objective is where AOM is confirmed or ruled out, so describe the tympanic membrane (TM) precisely rather than writing "red ear." Diagnosis hinges on a middle-ear effusion plus signs of acute inflammation.

• TM appearance: color (erythematous, opacified, hemorrhagic), contour (bulging vs neutral vs retracted).
• Effusion and mobility: air-fluid level or bubbles; reduced mobility on pneumatic otoscopy if performed.
• Integrity: intact vs perforation; presence and character of otorrhea.
• Laterality and the rest of the exam: document both ears, plus pharynx, nodes, lungs, and hydration to support the overall picture.

How do you document the antibiotic decision (treat vs observe)?

The Plan should show your reasoning, not just the prescription. Whether you treat immediately or use watchful waiting depends on age, severity, and laterality, so state the factors you weighed.

• Name the decision drivers: child's age, uni- vs bilateral disease, severity of pain, fever height, and parental reliability for follow-up.
• If observing: document the safety-net or delayed-prescription plan and the exact 48-72 hour follow-up trigger.
• If treating: record the agent, weight-based dose, frequency, and duration, plus penicillin-allergy alternatives when relevant.
• Always: include analgesia for pain and explicit return precautions.

A concrete pediatric SOAP note example for acute otitis media

Here is one realistic, original example. Adjust to your patient, local guidance, and clinical judgment.

S (Subjective)
3-year-old male, 15 kg, brought in by mother for 2 days of right ear pain and tugging.
Fever to 38.7 C at home last night. Decreased appetite and poor sleep. Preceding
runny nose for 4 days. No ear discharge, no neck stiffness, no post-auricular swelling,
no rash. No known drug allergies. Immunizations up to date. No tubes; one prior AOM.

O (Objective)
T 38.4 C, HR 120, RR 24, SpO2 99% RA. Alert, consolable, well hydrated.
Right TM: erythematous, bulging, opacified with loss of landmarks; reduced mobility on
pneumatic otoscopy; no perforation, no otorrhea.
Left TM: pearly gray, normal contour and landmarks, mobile.
Pharynx mildly erythematous, no exudate. Tonsils 1+. Nasal mucosa congested.
Neck supple, small mobile anterior cervical nodes. Lungs clear bilaterally.

A (Assessment)
Acute otitis media, right ear, moderate severity, with middle-ear effusion and bulging
TM. Unilateral disease in an otherwise well-appearing, hydrated 3-year-old. Concurrent
viral URI. No signs of mastoiditis or other complication.

P (Plan)
- Antibiotic: amoxicillin 90 mg/kg/day = ~675 mg PO twice daily for 10 days
  (weight 15 kg). No penicillin allergy.
- Analgesia: weight-based acetaminophen or ibuprofen as needed for pain/fever.
- Counsel: complete the full course; antibiotics treat the bacterial component.
- Return precautions: return or seek urgent care for worsening pain, fever beyond
  48-72 hours, ear discharge, redness/swelling behind the ear, neck stiffness,
  lethargy, or poor fluid intake.
- Follow-up: recheck if not improving in 48-72 hours; routine hearing follow-up if
  effusion persists. Verbal understanding confirmed with mother.

Tools like Doctor Notes can draft this structure from a recorded visit so the clinician edits rather than types, but the diagnosis, dosing, and return precautions remain the clinician's call.

Is amoxicillin always first-line for childhood AOM?

High-dose amoxicillin is a common first choice for uncomplicated AOM in children without a penicillin allergy or recent amoxicillin exposure. A broader agent may be preferred after recent antibiotics, with concurrent purulent conjunctivitis, or on treatment failure. Always confirm dosing against your patient's weight and current local guidance.

When is watchful waiting appropriate instead of antibiotics?

Observation with good pain control is an option for selected older children with non-severe, often unilateral disease and reliable follow-up. The key is documenting the shared decision and a clear 48-72 hour safety net so antibiotics start promptly if symptoms persist or worsen. Younger children and severe presentations are more likely to warrant immediate treatment.

How should return precautions be worded in the Plan?

Write precautions as specific, parent-actionable triggers rather than "return if worse." Name the symptoms that signal complication or failure: worsening pain, persistent high fever, new ear discharge, swelling behind the ear, neck stiffness, or lethargy. Pair them with a concrete timeframe so the family knows exactly when to come back.