soap-note

# SOAP Note Skill Good clinical documentation is structured so the next clinician can reconstruct the reasoning in seconds: what the patient reported, what was found, what you think, and what you'll do. This skill turns encounter notes into a clean SOAP note that follows that structure and keeps assessment separate from plan. > **Clinical-safety note:** this is a documentation-formatting aid, **not medical advice or a diagnosis**. It > organises information a qualified clinician provides; all content must be reviewed and verified by the treating > clinician before entering the medical record. Do not invent clinical findings, vitals, or results. ## Working from a brief Given rough encounter notes, **produce the full structured note anyway** — organise what's given into the four sections and place each detail correctly. Where a standard field wasn't provided, leave it clearly marked (e.g. "Vitals: not documented") rather than inventing a value. Never fabricate findings, labs, or measurements. ## Required Inputs Ask for these only if they aren't already provided (else mark as not documented): - **Subjective** — the patient's reported symptoms, history of present illness, relevant history. - **Objective** — exam findings, vitals, labs/imaging results (as provided). - **Clinical impression** — the working assessment / differential, if the clinician has one. - **Plan** — orders, treatment, follow-up, patient education (as provided). ## Output Format ### SOAP Note **S — Subjective** - Chief complaint, HPI (onset, location, duration, character, aggravating/relieving, timing, severity), pertinent history and ROS as provided. **O — Objective** - Vitals; physical exam by system; lab/imaging results. Only what was documented — mark anything absent as "not documented". **A — Assessment** - The working diagnosis/clinical impression, with a brief differential where relevant. Keep reasoning here, separate from the plan. **P — Plan** - Per problem: diagnostics ordered, treatment/medications, referrals, patient education, and follow-up. Numbered by problem when there are several. End with a note of any **fields not documented** and a reminder that the treating clinician must verify before filing. ## Quality Checks - [ ] Each detail is in the correct SOAP section (symptoms in S, findings in O, reasoning in A, actions in P) - [ ] Assessment is kept separate from plan — diagnosis vs. what you'll do - [ ] No clinical value (vital, lab, finding) is invented — undocumented fields are marked, not guessed - [ ] The plan is actionable and tied to the assessed problem(s) - [ ] Standard clinical structure and abbreviations are used appropriately - [ ] A clinician-review reminder is included ## Anti-Patterns - [ ] Do not invent vitals, labs, exam findings, or results to fill a section — mark them "not documented" - [ ] Do not present this as diagnosis or medical advice — it formats clinician-provided information - [ ] Do not blur assessment and plan into one block — they serve different readers and purposes - [ ] Do not drop pertinent negatives the clinician noted — they're part of the reasoning - [ ] Do not reorganise so heavily that the clinician's original meaning changes ## Based On Clinical documentation practice — the SOAP (Subjective, Objective, Assessment, Plan) format for structured, reviewable encounter notes.