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.