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