| 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
