SOAP note example: acute otitis media in a child

Ear infections in young children are common and usually settle, but the note has to show age, the eardrum findings on each side, the child's overall state and the antibiotic decision. Parents often phone back, and a clear note lets any colleague answer. Here are two invented pediatric notes and a guide to documenting each section.

Example: acute otitis media

S: 3-year-old girl, 2 days of right ear pain and pulling at the ear, fever up to 38.5 at home, runny nose for 4 days. Drinking well, passing urine normally. No vomiting, rash, drowsiness or discharge from the ear. No previous ear infections this year. Immunizations up to date per parent. Attends nursery. Paracetamol given with good effect.
O: Alert, playful between examinations. Weight 15 kg. Temp 38.2, pulse 120, RR 24, capillary refill under 2 seconds. Right tympanic membrane red and bulging, no perforation. Left tympanic membrane normal. Throat mildly red. No neck stiffness. No swelling or tenderness behind the ear. Chest clear.
A: Acute otitis media, right, unilateral, no otorrhea. Not systemically unwell. No signs of mastoiditis or meningitis.
P: 1. Paracetamol or ibuprofen for pain and fever, dose by weight.
2. Most settle in 3 days without antibiotics; explained to parent.
3. Delayed prescription: amoxicillin, weight-based dose, 5 days, to start if not improving after 3 days or worse sooner.
4. Return same day for swelling or redness behind the ear, stiff neck, drowsiness, persistent vomiting or not drinking.
5. Review if discharge from the ear or symptoms beyond 3 days.

Documenting each section for a child's ear infection

In Subjective, give age in years or months, onset and duration, ear pain or pulling, fever with the highest value, feeding and fluid intake, urine output, vomiting, drowsiness, rash, ear discharge, previous episodes, immunization status, and what has already been given.

Objective starts with general appearance and a full set of pediatric observations with weight, because doses and risk depend on them. Each tympanic membrane gets its own description: colour, bulging, perforation, discharge. Mastoid area, neck, throat and chest complete the picture.

The Assessment states side, laterality, discharge, and whether the child is systemically well. The Plan covers analgesia, the antibiotic choice (none, delayed or immediate) with the reason, the start conditions for a delayed prescription, return advice written for parents, and follow-up.

Example: follow-up with persistent effusion

S: 4-year-old boy, reviewed 6 weeks after a left ear infection. No pain or fever. Parent thinks he turns the TV up louder. Speech on track per nursery.
O: Well. Left tympanic membrane dull and retracted with fluid level, not red or bulging. Right tympanic membrane normal.
A: Left otitis media with effusion after acute infection. No acute infection.
P: Explained that fluid usually clears over weeks to months. Hearing test referral. Review in 3 months; ENT referral if persistent in both ears or hearing or speech affected.

What pediatric ear notes leave out

• Only the abnormal ear described, with the other side not mentioned.
• No weight, so weight-based doses cannot be checked.
• Fluid intake and urine output not asked.
• Delayed prescription given without saying when to start it.
• Mastoid and meningeal signs not stated as absent.

ICD-10 codes for otitis media

These are ICD-10-CM codes with laterality. Base ICD-10 uses H66.0 and H65 subcategories without the ear digit.

Pediatric visits with ClearPass

With a child on a lap and an otoscope in hand, typing is not an option. Transcribe, used once the parent agrees, keeps what the parent told you and what you called out while examining, and ClearPass writes it as a SOAP note with each eardrum described separately if you said so. Concise gives a short note; Detailed keeps every observation.

Weights, temperatures and doses are marked by the numbers check if they did not appear in the transcript. Patient instructions for parents, covering pain relief, when to start the delayed prescription and return symptoms, are one click. ICD-10 codes and a referral letter for hearing assessment are one click each. The note is a draft for you to review.

What ClearPass does not do

• It does not replace your judgement. Every note is an AI draft that you review and correct before it is used.
• It is not a medical device and does not make clinical decisions. It is a documentation aid.
• It does not connect to your EMR. The note is copy-ready text that pastes into any system.

Privacy

Clinical note content is not stored on ClearPass servers: it is processed to write the note, then discarded. Consultation audio is transcribed and discarded, never stored. Your note history stays in your browser, on your device, and you choose how long it is kept. Common identifiers are removed from typed and transcribed text before it reaches the AI; that is a best-effort safeguard, so leave names, ID numbers and file numbers out where you can. Processing goes through the AI providers named in our Privacy Policy, which sets out exactly what each one receives and how long it keeps it. ClearPass does not sign HIPAA business associate agreements today.

Questions

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