القائمة
Use when documenting a patient encounter in a structured clinical note format for medical records, communication, or billing
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npx skills add https://github.com/jeffreytse/grimoire-core --skill write-clinical-note-soapيبقى الأمر في سطر واحد. مرّر أفقيًا لمراجعته كاملًا قبل النسخ.
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| name | write-clinical-note-soap |
| description | Use when documenting a patient encounter in a structured clinical note format for medical records, communication, or billing |
| source | Weed "Medical Records, Medical Education, and Patient Care" (1969) SOAP originator; Joint Commission documentation standards; USMLE clinical skills documentation curriculum |
| tags | ["medicine","clinical-documentation","soap","medical-records"] |
| verified | true |
Document a patient clinical encounter using the SOAP format (Subjective, Objective, Assessment, Plan) to create a clear, legally defensible, and clinically actionable medical record.
Disclaimer: This skill is for documentation formatting assistance only, not medical advice. It is intended for use by licensed healthcare providers; it does not replace clinical judgment, diagnostic training, or consultation with a qualified healthcare provider.
Adopted by: Joint Commission accreditation standards for US hospitals, CMS (Centers for Medicare & Medicaid Services) documentation requirements, WHO patient safety records guidelines, all major EHR systems (Epic, Cerner, Athena).
Impact: SOAP-structured notes reduce medication errors by 23% and improve care team communication efficiency by 30% (Reisman & Brown 2016); poor clinical documentation contributes to 20% of adverse events due to miscommunication (WHO Patient Safety Report 2005); SOAP format is the global standard for 98% of clinical training programs.
Why best: Weed's problem-oriented medical record (POMR) with SOAP structure created a systematic, reproducible framework that separates data collection from clinical interpretation, preventing cognitive bias and ensuring complete documentation for medico-legal, billing, and continuity-of-care purposes.
Sources: Weed (1969) Year Book Medical Publishers; Joint Commission Standards RI.01.01.01; AMA CPT documentation guidelines (2019 update); Podder et al. StatPearls (2023).
Header — date, time, provider name and credentials, patient identifier, encounter type (in-person, telehealth, follow-up), relevant context (referral source, care setting).
S — Subjective — document the patient's own words and reported experience: chief complaint (CC) in direct quotes; history of present illness (HPI) using OLDCART or OPQRST framework (Onset, Location, Duration, Character, Aggravating/Alleviating factors, Radiation, Timing, Severity); pertinent past medical history, medications, allergies, family history, social history, and review of systems relevant to the CC.
HPI structure with OLDCART — for each symptom: Onset (when started, sudden vs. gradual), Location (where, does it radiate?), Duration (continuous vs. intermittent), Character (quality of symptom — burning, sharp, dull), Aggravating/Alleviating factors, Radiation, Timing (pattern), Severity (0–10 scale or functional impact).
O — Objective — document measurable, observable clinical data: vital signs (BP, HR, RR, temp, SpO2, weight, BMI); physical examination findings using systems (general, cardiovascular, respiratory, abdominal, neurological — only what is relevant); laboratory results (with reference ranges); imaging findings; EKG interpretation.
Objective writing conventions — use clinical descriptors: "lungs clear to auscultation bilaterally," "abdomen soft, non-tender, no organomegaly"; avoid subjective interpretations in this section; document both normal and abnormal findings relevant to the CC.
A — Assessment — state the working diagnosis and differential: primary diagnosis (most likely) first; ranked differential diagnoses with supporting and refuting evidence for each; ICD-10 code if required for billing; include severity, acuity, and complicating factors.
Assessment conventions — write as clinical reasoning: "32-year-old female presenting with 3-day productive cough, fever to 38.5°C, decreased breath sounds right base, and right lower lobe opacity on CXR, consistent with community-acquired pneumonia (J18.9)." Do not list diagnoses without clinical justification.
P — Plan — document specific actions for each problem listed in Assessment, organized by problem: diagnostics ordered (with clinical indication); medications prescribed (drug, dose, route, frequency, duration, number of refills); non-pharmacological interventions; referrals (to whom, urgency, indication); patient education provided; follow-up (timeframe and conditions for return).
Plan specificity — each plan element must be actionable and complete: "Amoxicillin 500 mg PO TID × 7 days for CAP; repeat CXR in 6 weeks to confirm resolution; return to ED if worsening dyspnea, O2 sat <94%, or inability to tolerate oral medications."
Sign and timestamp — physician signature (or co-signature for trainee), credentials, date and time of note completion. For billing compliance: attestation statement for supervising physician if note completed by resident or NP.
