clinical-notes

name	clinical-notes
description	Draft structured clinical documentation — SOAP notes, progress notes, admission and discharge summaries — from raw encounter data.
version	1.0.0
author	Gnostor Community
license	MIT
metadata	{"hermes":{"tags":["medical","clinical","documentation","SOAP","EMR","healthcare","notes"]}}

Clinical Notes

Turn raw clinical observations into structured, professional documentation that fits standard medical formats.

Disclaimer: This skill assists with documentation drafting only. It is not a clinical decision-support tool and does not replace professional judgment. All output must be reviewed and signed by a licensed clinician before entering the medical record.

When to Use

• "Write a SOAP note from these findings"
• "Draft a progress note for [patient scenario]"
• "Structure an admission H&P"
• "Write a discharge summary based on this hospitalization"
• "Convert these dictation notes into a formal clinical note"

What to Give Me

• Encounter type: outpatient visit, ED, admission, follow-up, discharge
• Raw data: subjective complaints, vitals, exam findings, labs/imaging, assessment, plan
• Specialty context (internal medicine, pediatrics, OB, surgery, psych, etc.)
• Format preferred: SOAP, narrative, problem-oriented, by-system
• Audience: chart documentation, referral letter, handoff

SOAP Format

**S — Subjective**
[Chief complaint, HPI, ROS, relevant history as reported by patient]

**O — Objective**
[Vitals, physical exam by system, labs, imaging, other studies]

**A — Assessment**
[Problem list with differential reasoning where relevant]
1. [Problem] — [working diagnosis, supporting findings]
2. [Problem] — [...]

**P — Plan**
By problem:
1. [Problem] — diagnostics, therapeutics, monitoring, follow-up
2. [Problem] — [...]

Disposition: [home / admit / referral]

Progress Note (Inpatient)

**HD #X / POD #X**
Patient: [age, sex, primary diagnosis]

**Overnight events:** [significant changes, new findings]

**Subjective:** [patient-reported status]

**Objective:**
- VS: [trends]
- Exam: [focused, by system]
- Labs/imaging: [new results, trends]

**Assessment & Plan by problem:**
1. [Active problem] — status, plan adjustments
2. [...]

Discharge Summary

**Admission Date / Discharge Date**
**Admitting Diagnosis / Discharge Diagnoses**

**Brief Hospital Course:**
[Narrative of admission, key events, response to treatment]

**Procedures / Consults:** [listed]

**Discharge Medications:** [reconciled list with changes noted]

**Discharge Instructions:**
- Activity / diet / wound care
- Follow-up appointments
- Red-flag symptoms requiring return

**Pending results at discharge:** [if any]

Documentation Principles

• Pertinent positives and negatives — both matter for medico-legal completeness
• Avoid copy-forward errors — flag anything that looks templated rather than current
• Problem-oriented when complex — multi-comorbidity patients deserve a problem list
• Defensible language — "consistent with" / "concerning for" rather than premature certainty
• Specialty conventions — OB uses GTPAL, peds uses growth percentiles, psych uses MSE