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

# 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.