automated-soap-note-generator

> **Source**: [https://github.com/aipoch/medical-research-skills](https://github.com/aipoch/medical-research-skills) # Automated SOAP Note Generator ## Quick Check Use this command to verify that the packaged script entry point can be parsed before deeper execution. ```bash python -m py_compile scripts/main.py ``` ## Audit-Ready Commands Use these concrete commands for validation. They are intentionally self-contained and avoid placeholder paths. ```bash python -m py_compile scripts/main.py python scripts/main.py --help python scripts/main.py --input "Audit validation sample with explicit symptoms, history, assessment, and next-step plan." --patient-id P12345 --provider "Dr. Smith" --format json ``` ## Workflow 1. Confirm the user objective, required inputs, and non-negotiable constraints before doing detailed work. 2. Validate that the request matches the documented scope and stop early if the task would require unsupported assumptions. 3. Use the packaged script path or the documented reasoning path with only the inputs that are actually available. 4. Return a structured result that separates assumptions, deliverables, risks, and unresolved items. 5. If execution fails or inputs are incomplete, switch to the fallback path and state exactly what blocked full completion. ## Overview AI-powered clinical documentation tool that converts unstructured clinical input into professionally formatted SOAP notes compliant with medical documentation standards. **Key Capabilities:** - **Intelligent Parsing**: Extracts structured information from free-text clinical narratives - **SOAP Classification**: Automatically categorizes content into Subjective, Objective, Assessment, Plan sections - **Medical Entity Recognition**: Identifies symptoms, diagnoses, medications, procedures, and anatomical locations - **Temporal Analysis**: Extracts timeline information (onset, duration, progression) - **Template Generation**: Produces standardized SOAP format suitable for EHR integration - **Multi-modal Input**: Accepts text dictation, transcripts, or clinical notes ## When to Use - Use this skill when the user provides de-identified clinical narratives, dictation, or transcripts and needs a structured SOAP note. - Use this skill when the output must clearly separate Subjective, Objective, Assessment, and Plan sections for clinical review. - Use this skill when you need a reproducible script-backed workflow with explicit assumptions, unresolved items, and fallback handling. ## Core Capabilities ### 1. Input Processing and Preprocessing Handle various input formats and prepare for NLP analysis: ```python from scripts.soap_generator import SOAPNoteGenerator generator = SOAPNoteGenerator() # Process text input soap_note = generator.generate( input_text="Patient presents with 2-day history of chest pain, radiating to left arm...", patient_id="P12345", encounter_date="2026-01-15", provider="Dr. Smith" ) # Process from audio transcript soap_note = generator.generate_from_transcript( transcript_path="consultation_transcript.txt", patient_id="P12345" ) ``` **Input Preprocessing Steps:** 1. **Text Cleaning**: Remove filler words ("um", "uh"), timestamps, speaker labels 2. **Sentence Segmentation**: Split into clinically meaningful segments 3. **Normalization**: Standardize abbreviations and medical shorthand 4. **Encoding Detection**: Handle various file formats (UTF-8, ASCII, etc.) **Parameters:** | Parameter | Type | Required | Description | Default | |-----------|------|----------|-------------|---------| | `input_text` | str | Yes* | Raw clinical text or dictation | None | | `transcript_path` | str | Yes* | Path to transcript file | None | | `patient_id` | str | No | Patient identifier (MUST be de-identified for testing) | None | | `encounter_date` | str | No | Date in ISO 8601 format (YYYY-MM-DD) | Current date | | `provider` | str | No | Healthcare provider name | None | | `specialty` | str | No | Medical specialty context | "general" | | `verbose` | bool | No | Include confidence scores | False | *Either `input_text` or `transcript_path` required **Best Practices:** - Always verify input text quality (clear audio → better transcription → better SOAP) - Remove patient identifiers before processing unless in secure environment - Split long encounters (>30 minutes) into logical segments - Flag ambiguous abbreviations for manual review ### 2. Medical Named Entity Recognition (NER) Identify and extract medical concepts from unstructured text: ```python # Extract entities with context entities = generator.extract_medical_entities( "Patient has history of hypertension and diabetes, currently taking lisinopril 10mg daily and metformin 500mg BID" ) # Returns structured entities: # { # "diagnoses": ["hypertension", "diabetes mellitus"], # "medications": [ # {"name": "lisinopril", "dose": "10mg", "frequency": "daily"}, # {"name": "metformin", "dose": "500mg", "frequency": "BID"} # ] # } ``` **Entity Types Recognized:** | Category | Examples | Notes | |----------|----------|-------| | **Diagnoses** | diabetes, hypertension, pneumonia | ICD-10 compatible where possible | | **Symptoms** | chest pain, headache, nausea | Includes severity modifiers | | **Medications** | metformin, lisinopril, aspirin | Extracts dose, route, frequency | | **Procedures** | ECG, CT scan, blood draw | Includes body site | | **Anatomy** | left arm, chest, abdomen | Laterality and location | | **Lab Values** | glucose 120, BP 140/90 | Units and reference ranges | | **Temporal** | yesterday, 3 days ago, chronic | Normalized to relative dates | **Common Issues and Solutions:** **Issue: Missed medications** - Symptom: Generic names not recognized (e.g., "water pill" for diuretic) - Solution: Manual review required; tool flags colloquial terms for verification **Issue: Ambiguous abbreviations** - Symptom: "SOB" could be shortness of breath or something else - Solution: Context-aware disambiguation; flag uncertain cases **Issue: Misspelled drug names** - Symptom: "metfomin" instead of "metformin" - Solution: Fuzzy matching with confidence threshold; flag low-confidence matches ### 3. SOAP Section Classification Automatically categorize sentences into appropriate SOAP sections: ```python # Classify content into SOAP sections classified = generator.classify_soap_sections( "Patient reports chest pain for 2 days. Physical exam shows BP 140/90. Likely angina. Schedule stress test and start aspirin 81mg daily." ) # Output structure: # { # "Subjective": ["Patient reports chest pain for 2 days"], # "Objective": ["Physical exam shows BP 140/90"], # "Assessment": ["Likely angina"], # "Plan": ["Schedule stress test", "start aspirin 81mg daily"] # } ``` **Classification Rules:** | Section | Content Type | Examples | |---------|--------------|----------| | **S** - Subjective | Patient-reported information | "Patient states...", "Patient reports...", "Complains of..." | | **O** - Objective | Observable/measurable findings | Vital signs, physical exam, lab results, imaging | | **A** - Assessment | Clinical interpretation | Diagnosis, differential, clinical impression | | **P** - Plan | Actions to be taken | Medications, procedures, follow-up, patient education | **Multi-label Handling:** Some sentences span multiple sections (e.g., "Patient reports chest pain [S], which was sharp and 8/10 [S], with ECG showing ST elevation [O]") - Tool splits compound sentences at conjunctions - Assigns primary and secondary labels with confidence scores **Best Practices:** - Review classification accuracy, especially for complex multi-part statements - Manually verify Assessment section (most critical for patient care) - Ensure temporal context preserved (recent vs. chronic symptoms) ### 4. Temporal Information Extraction Parse and normalize timeline information: ```python # Extract temporal relationships timeline = generator.extract_temporal_info( "Patient had chest pain starting 3 days ago, worsening since yesterday. Had similar episode 2 months ago that resolved with rest." ) # Returns: # { # "onset": "3 days ago", # "progression": "worsening", # "previous_episodes": [ # {"time": "2 months ago", "resolution": "with rest"} # ] # } ``` **Temporal Elements Extracted:** - **Onset**: When symptoms started ("2 days ago", "this morning") - **Duration**: How long symptoms lasted ("for 3 hours", "ongoing") - **Frequency**: How often symptoms occur ("daily", "intermittently") - **Progression**: Getting better/worse/stable - **Prior Episodes**: Previous similar events - **Context**: "before meals", "with exertion", "at night" **Normalization:** Converts relative dates to standardized format: - "yesterday" → Encounter date minus 1 day - "3 days ago" → Specific date calculated - "chronic" → Flagged for chronic condition tracking ### 5. Negation and Uncertainty Detection Critical for accurate medical documentation: ```python # Detect negations and uncertainties analysis = generator.analyze_certainty( "Patient denies chest pain. No shortness of breath. Possibly had fever yesterday but not sure." ) # Identifies: # - "denies chest pain" → Negative finding (important!) # - "No shortness of breath" → Negative finding # - "Possibly had fever" → Uncertain finding (flag for verification) ``` **Detection Categories:** | Type | Cues | Action | |------|------|--------| | **Negation** | denies, no, without, absent | Mark as negative finding | | **Uncertainty** | possibly, maybe, uncertain, ? | Flag for physician review | | **Hypothetical** | if, would, could | Note as conditional | | **Family History** | family history of, mother had | Separate from patient findings | **⚠️ Critical:** Negation errors are high-risk (e.g., missing "denies" → documenting symptom they don't have) - Always verify negative findings in Subjective section - Uncertain findings must be explicitly marked for review ### 6. Structured SOAP Generation Produce final formatted output: ```python # Generate complete SOAP note soap_output = generator.generate_soap_document( structured_data=classified, format="markdown", # Options: markdown, json, hl7, text include_metadata=True ) ``` **Output Format:** ```markdown # SOAP Note **Patient ID:** P12345 **Date:** 2026-01-15 **Provider:** Dr. Smith ## Subjective Patient reports [extracted symptoms with duration]. History of [chronic conditions]. Currently taking [medications]. Patient denies [negative findings]. ## Objective **Vital Signs:** [BP, HR, RR, Temp, O2Sat] **Physical Examination:** [Exam findings by system] **Laboratory/Data:** [Relevant results] ## Assessment [Primary diagnosis/differential] [Clinical reasoning summary] ## Plan 1. [Action item 1] 2. [Action item 2] 3. [Follow-up instructions] --- *Generated by AI. REQUIRES PHYSICIAN REVIEW before entry into patient record.* ``` **Export Formats:** | Format | Use Case | Notes | |--------|----------|-------| | **Markdown** | Human review, documentation | Default, readable | | **JSON** | System integration, research | Structured data | | **HL7 FHIR** | EHR integration | Healthcare standard | | **Plain Text** | Simple documentation | Minimal formatting | | **CSV** | Data analysis, research | Tabular data export | ## Limitations - **Not a diagnostic tool**: Cannot make medical decisions or diagnoses - **Specialty coverage**: Best performance in internal medicine, family practice; variable in highly specialized fields - **Language**: Optimized for English; limited support for other languages - **Context window**: May lose context in very long, complex encounters - **Ambiguity**: Struggles with highly ambiguous or contradictory input - **Rare conditions**: May not recognize very rare diseases or new medications - **Non-verbal cues**: Cannot interpret tone, emphasis, or non-verbal information from audio ## Parameters | Parameter | Type | Default | Required | Description | |-----------|------|---------|----------|-------------| | `--input`, `-i` | string | - | No | Input clinical text directly | | `--input-file`, `-f` | string | - | No | Path to input text file | | `--output`, `-o` | string | - | No | Output file path | | `--patient-id`, `-p` | string | - | No | Patient identifier | | `--provider` | string | - | No | Healthcare provider name | | `--format` | string | markdown | No | Output format (markdown, json) | ## Usage ### Basic Usage ```text # Generate SOAP from text python scripts/main.py --input "Patient reports chest pain..." --output note.md # From file python scripts/main.py --input-file consultation.txt --patient-id P12345 --provider "Dr. Smith" # JSON output python scripts/main.py --input-file notes.txt --format json --output note.json