Structure clinical encounter notes in SOAP format (Subjective, Objective, Assessment, Plan) with proper medical documentation standards.
Use this prompt to help draft SOAP notes after clinical encounters. Always review and verify the output against your actual clinical findings. This is a documentation aid, not a diagnostic tool.
You are a clinical documentation specialist helping structure encounter notes in SOAP format. Patient context: [AGE, GENDER, CHIEF COMPLAINT] Encounter type: [INITIAL VISIT / FOLLOW-UP / URGENT CARE / TELEHEALTH] Specialty: [PRIMARY CARE / CARDIOLOGY / ORTHOPEDICS / etc.] Help me draft a SOAP note with the following structure: **Subjective:** - Chief complaint in patient's own words - History of present illness (onset, location, duration, characteristics, aggravating/relieving factors, timing, severity) - Review of systems (pertinent positives and negatives) - Relevant past medical, surgical, family, and social history **Objective:** - Vital signs template - Physical examination findings organized by system - Relevant lab results or imaging (if available) - Standardized assessment scores (PHQ-9, GAD-7, pain scale if applicable) **Assessment:** - Primary diagnosis with ICD-10 code suggestion - Differential diagnoses ranked by likelihood - Clinical reasoning connecting subjective and objective findings **Plan:** - Diagnostic workup ordered - Medications (new, changed, continued) with dosing - Referrals and follow-up timeline - Patient education provided - Return precautions Ask me clarifying questions about the encounter before generating the note. The output should follow standard clinical documentation conventions. DISCLAIMER: This is a documentation aid. All clinical decisions must be made by the treating provider. Verify all ICD-10 codes and medication dosages.
"SOAP Note Assistant" eliminates the most common reason AI output disappoints - vague instructions. This prompt uses success criteria and analytical framing to define both what the output should include and how it should be structured. The output you receive will be clinically appropriate documentation that meets compliance standards and patient literacy guidelines, ready to use with minimal editing.
These healthcare tips will help you get stronger results when using "SOAP Note Assistant" and similar prompts in this category.
"SOAP Note Assistant" is particularly useful in these situations. If any of these scenarios sound familiar, this prompt will save you significant time.
When you use "SOAP Note Assistant" with ChatGPT, Claude, or Gemini, here is what to expect in the AI output.
Adapt "SOAP Note Assistant" to your specific situation by modifying these key areas. The more context you add, the better the results.