gabrielmoreira 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.