Draft a SOAP note from the encounter information below. I am responsible for clinical judgment, final documentation, coding, and care decisions; do not replace those functions. Patient context and reason for visit: [PATIENT CONTEXT] Subjective history and patient-reported words: [SUBJECTIVE NOTES] Objective findings, vitals, tests, and observations: [OBJECTIVE FINDINGS] My assessment, decisions, and instructions given: [CLINICIAN ASSESSMENT AND PLAN] Documentation standard and desired detail: [SETTING AND FORMAT]
Use the SOAP structure exactly: S: concise HPI and relevant symptoms, pertinent negatives only when documented, relevant history, and patient-reported response. Clearly distinguish patient report from observed fact. O: vitals, exam, lab or imaging results, and measurable observations. Do not convert an absent note into a normal finding. A: list only the diagnoses, differential, risk assessment, or clinical reasoning I supplied. Preserve uncertainty and do not add diagnoses or severity. P: medications, orders, referrals, education, return precautions, follow-up interval, and responsibilities exactly as documented. If an instruction is missing, mark “not documented” rather than supplying it. Write in neutral clinical language with standard abbreviations only where unambiguous for the stated setting. Produce a complete note, then a short “items requiring clinician confirmation” list. Before answering, check that no medication dose, test result, diagnosis, allergy, or follow-up instruction was invented. Also flag conflicts between the subjective report, objective findings, and stated assessment. Ask up to 3 clarifying questions only if a required input is missing.
Fill in
| Placeholder | What to enter | Example |
|---|---|---|
| [PATIENT CONTEXT] | Enter the de-identified patient context and the reason for the encounter. | De-identified adult outpatient follow-up for persistent cough, day 6 |
| [SUBJECTIVE NOTES] | Enter the patient-reported history, symptoms, relevant negatives, and concerns. | Reports dry cough and congestion improving; denies fever, chest pain, shortness of breath, and hemoptysis; using fluids and honey; no new medications |
| [OBJECTIVE FINDINGS] | Enter documented vitals, examination findings, tests, and observations. | Temp 98.4 F, pulse 78, SpO2 98% room air; speaking full sentences; lungs clear to auscultation; no respiratory distress |
| [CLINICIAN ASSESSMENT AND PLAN] | Enter your assessment, decisions, orders, medication instructions, and follow-up plan. | Likely viral upper respiratory infection; continue supportive care; no antibiotics indicated; return for fever, dyspnea, chest pain, or symptoms lasting beyond 2 weeks; follow up as needed |
| [SETTING AND FORMAT] | Enter the clinical setting and any required template, payer, or length convention. | Primary-care EHR SOAP note, concise, no billing codes |
How to use
- Remove direct identifiers and paste your contemporaneous encounter notes under each field.
- State your actual assessment and orders before asking for a draft; do not ask the model to infer a diagnosis or treatment.
- Compare the generated note line by line with the source record, especially doses, dates, negatives, and return precautions.
- Follow up with: “Shorten this to our EHR’s 250-word limit without removing any documented safety instruction.”
Variations
Therapy session
Use this for behavioral-health documentation with a defined treatment focus.
Draft a de-identified psychotherapy SOAP note from [SESSION NOTES], [MENTAL STATUS FINDINGS], [RISK ASSESSMENT], and [INTERVENTIONS AND PLAN]. Use neutral, trauma-informed language. Distinguish client statements from clinician observations and document risk only as supplied. Produce S, O, A, and P plus a clinician-confirmation list. Do not invent diagnoses, safety contracts, progress, quotes, or treatment techniques. Check that the plan matches the documented risk level and stated interventions. Ask up to 3 questions only if required inputs are missing.
Nursing handoff
Use this when converting shift observations into a concise clinical handoff.
Create a structured nursing SOAP handoff from [PATIENT STATUS], [SHIFT EVENTS], [MEDICATIONS AND ORDERS], and [PENDING TASKS]. Include current condition, relevant assessments, interventions completed, response, abnormalities, and exact items for the next shift. Keep timestamps, doses, and provider notifications exactly as given. Do not infer normal findings or add recommendations that were not ordered. Flag conflicting times, values, or orders before the handoff. Ask up to 3 questions only if a necessary input is absent.
Patient message
Use this for a portal response after the clinician has set the guidance.
Write a patient portal message based only on [CLINICIAN GUIDANCE], [PATIENT QUESTION], and [APPROVED FOLLOW-UP]. Use plain language, state the next step and any supplied warning signs, and avoid diagnosing beyond the clinician’s statement. Keep it under [WORD LIMIT] words. Do not add medication changes, timelines, or reassurance not in the source. End with the approved contact or escalation instruction. Check every action item against the guidance. Ask up to 3 questions only if required information is missing.
Tips
- Use “patient reports” for symptoms and “exam shows” for findings so the provenance of each statement remains clear.
- If a field was not assessed, leave it absent or label it according to your organization’s convention; never let AI fill it with a normal result.
- Give the model the plan you decided on, including exact return precautions, rather than asking it to choose treatment.
- Do not paste identifying details into a general-purpose tool unless your organization has approved the tool and workflow for protected health information.
FAQ
Can AI create a SOAP note from a recording?
Only use an approved, privacy-compliant workflow and review the transcription closely. Clinical context, negations, and medication details are common transcription failure points.
Can the model write the assessment for me?
It can format your documented reasoning, but the clinician must make the assessment and determine the plan. Do not accept new diagnoses or orders generated from incomplete notes.
Will this produce a billable note?
It can organize documentation, but billing and coding requirements vary by discipline, payer, and jurisdiction. Confirm required elements with your organization.