Disclaimer:
This document is for educational and workflow support only and is not medical advice. It was generated with the assistance of AI. Errors may occur; all content must be carefully reviewed, edited, and verified by a licensed provider. Liability rests with the clinician who adopts and signs the documentation.
Chat GPT Prompt
Act as a nurse practitioner and write a detailed SOAP note for a pediatric patient with Acute Otitis Media. In the Plan, include supportive care and add return precautions with emphasis on seeking care sooner if red flag symptoms develop.
SOAP Note – Pediatric Acute Otitis Media (AOM)
S: Subjective
CC: Ear pain x ____ days.
Parent/patient reports ____ [fussiness, irritability, ear tugging, poor sleep, ↓ appetite].
Associated symptoms: ____ [nasal congestion, rhinorrhea, cough, sore throat, fever, vomiting, diarrhea, rash, lethargy].
Recent illness/exposures: ____.
Prior ear infections: Yes / No.
Appetite/fluids: ____ [normal, ↓, poor intake].
Allergies: ____.
Meds: ____.
ROS (10+ systems)
- Constitutional: ____ [fever, chills, fatigue, weight changes, none]
- Eyes: ____ [redness, discharge, pain, vision change, none]
- ENT: +Ear pain; ____ [congestion, rhinorrhea, sore throat, hearing change, none]
- CV: ____ [chest pain, palpitations, none]
- Resp: ____ [cough, SOB, wheezing, none]
- GI: ____ [nausea, vomiting, diarrhea, abdominal pain, none]
- GU: ____ [dysuria, frequency, hematuria, none]
- MSK: ____ [myalgias, arthralgias, none]
- Skin: ____ [rash, lesions, none]
- Neuro: ____ [headache, dizziness, weakness, none]
- Psych: ____ [irritability, behavior changes, sleep disturbance, none]
O: Objective
VS: T ____ °F HR ____ BP ____ RR ____ SpO₂ ____%
General: ____ [alert, playful, consolable, irritable, NAD].
HEENT:
- Right ear: TM ____ [erythematous, bulging, dull, normal]; ____ [perforation/drainage present/absent].
- Left ear: TM ____ [erythematous, bulging, dull, normal]; ____ [perforation/drainage present/absent].
- Oropharynx: ____ [moist, erythematous, exudate].
- Nose: ____ [clear, congested, rhinorrhea].
Neck: ____ [supple, lymphadenopathy present/absent].
CV: ____ [RRR, murmurs present/absent].
Resp: ____ [clear, wheezes, rhonchi, rales].
Abdomen: ____ [soft, nontender, nondistended].
Skin: ____ [warm, dry, rash present/absent].
Neuro: ____ [alert, age-appropriate, no focal deficit].
A: Assessment
Acute otitis media, ____ [right/left/bilateral].
ICD-10: H66.001 (right), H66.002 (left), H66.003 (bilateral), H66.009 (unspecified).
P: Plan
Diagnostics: ____ [none, tympanometry, strep/flu/COVID as indicated].
Management:
- Antibiotic: ____ [choice/dose per protocol if indicated].
- Supportive care: acetaminophen/ibuprofen for pain/fever, warm compress, hydration, rest.
Education: Discussed natural course, supportive care, antibiotic rationale.
Return Precautions: Return sooner for fever >102.5°F, worsening ear pain, new drainage, swelling/redness behind ear, persistent vomiting, poor fluid intake, lethargy, or no improvement in 48–72 hrs.
Follow-up: PCP/clinic in ~1 week, sooner if red flags.
⚠️ Disclaimer: This is a generic documentation template for educational/support purposes only. Not a substitute for clinical judgment. Must be tailored to the patient.