create-soap-note

# Create SOAP Note This skill defines the workflow for creating structured medical documentation (SOAP notes) by writing comprehensive content directly to a file. It ensures all standard sections are included and properly formatted. ## Objective Produce a complete medical visit record containing Subjective, Objective, Assessment, and Plan sections without fragmenting the output across multiple files or incomplete drafts. ## Prerequisites - Patient demographic information (age, gender, ID). - Visit details (date, provider, reason for visit). - Clinical data (vitals, symptoms, exam findings, history). ## Workflow Steps ### 1. Prepare Content Structure Organize the note into the four standard SOAP sections. Do not omit any section even if data is sparse (note "not applicable" or "deferred" where appropriate). ### 2. Draft Comprehensive Content Write the full content for each section in one continuous operation. Avoid placeholders like `[insert here]` unless data is genuinely missing and must be flagged for follow-up. - **Subjective (S):** - Chief Complaint (CC) - History of Present Illness (HPI) - Past Medical History (PMH) - Family/Social History (FH/SH) - Review of Systems (ROS) - **Objective (O):** - Vitals (BP, HR, Temp, Resp, O2 Sat, Weight/Height) - Physical Exam (by system) - Diagnostic Results (Labs, Imaging) - **Assessment (A):** - Primary Diagnosis - Differential Diagnoses - Problem List - **Plan (P):** - Management/Treatment - Medications - Follow-up Instructions - Patient Education ### 3. Write to File Save the complete note to a single file (e.g., `soap_note_<patient_id>_<date>.md` or `.txt`). Ensure the file is saved in one write operation to maintain consistency. ### 4. Review for Completeness Verify that all four headers exist and contain substantive content. ## Template Example ```markdown # SOAP Note - [Patient Name] - [Date] ## Subjective **Chief Complaint:** [Reason for visit] **HPI:** [Detailed history] **PMH:** [Conditions, surgeries] **Social/Family History:** [Relevant details] ## Objective **Vitals:** [List values] **Physical Exam:** [Findings by system] **Labs/Imaging:** [Results] ## Assessment **Diagnoses:** 1. [Primary Diagnosis] 2. [Differential] ## Plan **Management:** [Steps taken] **Medications:** [Prescriptions] **Follow-up:** [Timeline] **Education:** [Instructions given] ``` ## Best Practices - **Privacy:** Ensure no real PHI (Protected Health Information) is exposed in public logs if not authorized. - **Clarity:** Use medical terminology appropriately but keep patient instructions clear. - **Efficiency:** Aim to generate the full document in one iteration to reduce overhead. ## Troubleshooting - **Missing Data:** If specific clinical data is missing, explicitly state "Information not provided" in the relevant section rather than skipping the section. - **File Size:** If the note is exceptionally long, ensure the file write command supports the content length.