Date:
Patient: [Patient Name], [Age], [MRN]
Attending Physician: [Physician Name]
Reason for Visit: Follow-up for childhood obesity, evaluation of weight management progress, or initial evaluation for suspected obesity.
SOAP
Subjective (S):
History of Present Illness:
Inquire about the reason for the visit. This may include:
For established diagnosis:
Progress with weight management efforts since the last visit.
Any challenges or successes encountered with diet, exercise, or behavior changes.
Presence of any weight-related symptoms (e.g., fatigue, joint pain, sleep apnea symptoms).
For suspected diagnosis: Concerns about the child’s weight or growth pattern.
Past Medical History:
Briefly summarize relevant past medical history, including:
Birth history (gestational weight, complications)
Previous diagnoses potentially related to weight (e.g., polycystic ovary syndrome, hypothyroidism)
Family history of obesity or weight-related complications (e.g., type 2 diabetes, heart disease)
Social History:
Inquire about dietary habits, physical activity level, and sleep patterns:
Typical daily intake (consider using a 24-hour dietary recall).
Frequency and duration of physical activity (structured and unstructured).
Screen time habits (television, video games).
Sleep duration and quality.
Socioeconomic factors that may influence healthy habits (e.g., access to healthy food, safe places for exercise).
Objective (O):
Vital Signs:
Record temperature, heart rate, blood pressure, and respiratory rate.
Anthropometrics:
Measure and record weight, height, and body mass index (BMI) for age and calculate percentile.
Consider waist circumference measurement if appropriate.
Physical Exam:
Perform a focused physical exam to assess for:
Signs of potential weight-related complications (e.g., acanthosis nigricans, fatty liver stigmata).
Joint pain or limitations.
Blood pressure measurement.
Assessment (A):
Weight Status:
Based on BMI for age percentile, classify the child’s weight status as underweight, normal weight, overweight, or obese.
Severity of Childhood Obesity (if applicable):
If obesity is present, consider using additional criteria (e.g., presence of weight-related comorbidities) to assess the severity.
Differential Diagnosis (if weight gain is rapid or unexplained):
Briefly consider other causes of weight gain, such as:
Endocrine disorders (e.g., hypothyroidism)
Medications with weight gain as a side effect
Plan (P):
Weight Management Plan:
Develop a personalized weight management plan in collaboration with the family, considering:
Dietary modifications: Focus on a balanced diet with appropriate portion sizes, increased fruits and vegetables, and reduced sugary drinks.
Increased physical activity: Encourage regular physical activity (aim for at least 60 minutes most days) and reducing sedentary time.
Behavioral changes: Address underlying factors that contribute to unhealthy habits (e.g., stress management, sleep hygiene).
Consider referral to a registered dietitian or certified personal trainer for additional support.
Monitoring:
Schedule regular follow-up visits to monitor weight, growth, and response to the weight management plan.
Consider additional testing (e.g., blood tests) if indicated by clinical presentation or concerns about weight-related complications.
Patient and Family Education:
Educate the patient and family about childhood obesity, healthy eating habits, importance of physical activity, and strategies for behavior change.
Provide resources and support groups for families managing childhood obesity.
Additional Interventions (if indicated):
Consider referral to a psychologist or therapist to address emotional factors related to weight management.
If obesity is severe or complications are present, discuss the potential role of medications or bariatric surgery (in adolescents) with a specialist.
Additional Notes:
Document any other relevant information, such as:
Communication with consulting physicians (e.g., endocrinologist)
Addressing psychosocial factors that might contribute to weight issues (e.g., bullying, emotional eating).
Importance of a positive and supportive approach to weight management for the child.