SOAP Note Creation
This skill captures the pattern of creating complete, structured medical documentation (SOAP notes) by writing all required sections to a file in one iteration.
When to Use
Use this skill when you need to create medical meeting notes, patient visit documentation, or clinical encounter records that follow the standard SOAP format.
Core Technique
Write the entire SOAP note in one comprehensive file write rather than building it incrementally. This ensures completeness and consistency across all sections.
Required Sections
Every SOAP note must include these four components:
1. Subjective (S)
- Chief Complaint (CC): Patient's primary reason for visit
- History of Present Illness (HPI): Detailed narrative of current symptoms
- Past Medical History (PMH): Relevant medical history, medications, allergies
- Family/Social History: Pertinent family and social context
2. Objective (O)
- Vital Signs: BP, HR, RR, Temp, SpO2, weight, height
- Physical Examination: System-by-system findings (HEENT, Cardiovascular, Respiratory, Abdomen, Neurological, etc.)
- Diagnostic Data: Lab results, imaging findings if available
3. Assessment (A)
- Primary Diagnosis: Main clinical diagnosis
- Differential Diagnoses: Alternative considerations
- Clinical Reasoning: Brief justification for assessment
4. Plan (P)
- Management: Treatments, medications, interventions
- Follow-up: Timing and conditions for return
- Patient Education: Instructions, lifestyle modifications, warning signs
Execution Pattern
1. Gather all patient information and clinical data
2. Structure content into the four SOAP sections
3. Write the complete note to file in ONE operation
4. Verify all four sections are present and complete
Example Structure
# SOAP Note - [Patient Name/ID]
## Date: [Visit Date]
## SUBJECTIVE
### Chief Complaint
[Patient's reason for visit in their own words]
### History of Present Illness
[Detailed symptom narrative using OLDCARTS or similar framework]
### Past Medical History
[Relevant conditions, surgeries, medications, allergies]
### Family/Social History
[Relevant family history and social context]
## OBJECTIVE
### Vital Signs
- BP: [value]
- HR: [value]
- Temp: [value]
- [etc.]
### Physical Examination
- **HEENT**: [findings]
- **Cardiovascular**: [findings]
- **Respiratory**: [findings]
- **Abdomen**: [findings]
- **Neurological**: [findings]
- [etc.]
### Diagnostic Data
[Labs, imaging, other test results]
## ASSESSMENT
### Primary Diagnosis
[Diagnosis with ICD code if applicable]
### Differential Diagnoses
1. [Alternative 1]
2. [Alternative 2]
### Clinical Reasoning
[Brief explanation linking findings to diagnosis]
## PLAN
### Management
- [Medications with dose/frequency]
- [Procedures/interventions]
- [Referrals if needed]
### Follow-up
[Timeline and conditions for return visit]
### Patient Education
[Instructions, lifestyle mods, warning signs to watch]
Best Practices
- Completeness First: Include all four sections before writing—do not build incrementally
- Specificity: Use concrete values (vitals, dates, doses) rather than placeholders
- Clinical Accuracy: Ensure assessment logically follows from subjective and objective data
- Actionable Plan: Plan items should be specific and implementable
- File Size: Comprehensive notes typically range 3000-8000 bytes depending on complexity
Common Mistakes to Avoid
- Writing sections separately across multiple iterations
- Leaving sections incomplete or with placeholder text
- Omitting differential diagnoses in Assessment
- Creating vague, non-actionable Plan items
- Missing vital signs or key physical exam findings
1---2name: soap-note-creation3description: Create structured medical SOAP notes with all four components in a single comprehensive file write4---5
6# SOAP Note Creation
7
8This skill captures the pattern of creating complete, structured medical documentation (SOAP notes) by writing all required sections to a file in one iteration.
9
10## When to Use
11
12Use this skill when you need to create medical meeting notes, patient visit documentation, or clinical encounter records that follow the standard SOAP format.
13
14## Core Technique
15
16Write the **entire SOAP note in one comprehensive file write** rather than building it incrementally. This ensures completeness and consistency across all sections.
17
18## Required Sections
19
20Every SOAP note must include these four components:
21
22### 1. Subjective (S)
23- **Chief Complaint (CC)**: Patient's primary reason for visit
24- **History of Present Illness (HPI)**: Detailed narrative of current symptoms
25- **Past Medical History (PMH)**: Relevant medical history, medications, allergies
26- **Family/Social History**: Pertinent family and social context
27
28### 2. Objective (O)
29- **Vital Signs**: BP, HR, RR, Temp, SpO2, weight, height
30- **Physical Examination**: System-by-system findings (HEENT, Cardiovascular, Respiratory, Abdomen, Neurological, etc.)
31- **Diagnostic Data**: Lab results, imaging findings if available
32
33### 3. Assessment (A)
34- **Primary Diagnosis**: Main clinical diagnosis
35- **Differential Diagnoses**: Alternative considerations
36- **Clinical Reasoning**: Brief justification for assessment
37
38### 4. Plan (P)
39- **Management**: Treatments, medications, interventions
40- **Follow-up**: Timing and conditions for return
41- **Patient Education**: Instructions, lifestyle modifications, warning signs
42
43## Execution Pattern
44
45```
461. Gather all patient information and clinical data
472. Structure content into the four SOAP sections
483. Write the complete note to file in ONE operation
494. Verify all four sections are present and complete
50```
51
52## Example Structure
53
54```markdown
55# SOAP Note - [Patient Name/ID]
56## Date: [Visit Date]
57
58## SUBJECTIVE
59### Chief Complaint
60[Patient's reason for visit in their own words]
61
62### History of Present Illness
63[Detailed symptom narrative using OLDCARTS or similar framework]
64
65### Past Medical History
66[Relevant conditions, surgeries, medications, allergies]
67
68### Family/Social History
69[Relevant family history and social context]
70
71## OBJECTIVE
72### Vital Signs
73- BP: [value]
74- HR: [value]
75- Temp: [value]
76- [etc.]
77
78### Physical Examination
79- **HEENT**: [findings]
80- **Cardiovascular**: [findings]
81- **Respiratory**: [findings]
82- **Abdomen**: [findings]
83- **Neurological**: [findings]
84- [etc.]
85
86### Diagnostic Data
87[Labs, imaging, other test results]
88
89## ASSESSMENT
90### Primary Diagnosis
91[Diagnosis with ICD code if applicable]
92
93### Differential Diagnoses
941. [Alternative 1]
952. [Alternative 2]
96
97### Clinical Reasoning
98[Brief explanation linking findings to diagnosis]
99
100## PLAN
101### Management
102- [Medications with dose/frequency]
103- [Procedures/interventions]
104- [Referrals if needed]
105
106### Follow-up
107[Timeline and conditions for return visit]
108
109### Patient Education
110[Instructions, lifestyle mods, warning signs to watch]
111```
112
113## Best Practices
114
1151. **Completeness First**: Include all four sections before writing—do not build incrementally
1162. **Specificity**: Use concrete values (vitals, dates, doses) rather than placeholders
1173. **Clinical Accuracy**: Ensure assessment logically follows from subjective and objective data
1184. **Actionable Plan**: Plan items should be specific and implementable
1195. **File Size**: Comprehensive notes typically range 3000-8000 bytes depending on complexity
120
121## Common Mistakes to Avoid
122
123- Writing sections separately across multiple iterations
124- Leaving sections incomplete or with placeholder text
125- Omitting differential diagnoses in Assessment
126- Creating vague, non-actionable Plan items
127- Missing vital signs or key physical exam findings
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