SOAP Note Generator From Visit Notes

In the US, the Centers for Medicare & Medicaid Services (CMS) sets out what each visit's record should hold. Its guide lists the reason for the visit and relevant history, exam findings, prior test results, your assessment, and the plan of care¹. SOAP arranges them in the order you gather them.

Open with the chief complaint. CMS describes it as a short statement of the symptom, problem, condition, diagnosis or reason for the visit¹, usually in the patient's own words. Quote them when the words matter: "I get winded on the stairs" tells the reader more than "dyspnea on exertion."

Then write the history of the present illness. Cover when it started, where it is, what it feels like, how severe it is, what eases or worsens it and what has been tried. Record the negatives that matter, such as no fever with a new cough, not a habitual full review of systems.

Under the American Medical Association's coding guidelines, the care team may collect history, and patients may supply it by portal or questionnaire², as long as you review it. An intake form can gather much of it before the visit. Whoever collects it, confirm medications and allergies every time.

In a hospital progress note, the subjective part opens with overnight events, and the daily notes later feed the discharge summary.

Give vital signs, the findings for systems you actually examined, and results with values and dates. Put a trend beside the number: "A1c 8.1%, up from 7.4% in March" says more than either value alone.

Templates and copying are where this part goes wrong. A 2014 report by the HHS Office of Inspector General warned that some record systems generate extensive documentation from a single click of a checkbox³. Unedited, that text may be inaccurate, the report said, and so may copied text that isn't updated.

In a 2022 JAMA Network Open study of 104 million notes written at Penn Medicine from 2015 to 2020, 50.1% of the text had been duplicated from earlier documentation⁴. If you carry text forward, reread every line and update what has changed.

Number each problem you addressed, starting with the reason for the visit. Under the AMA's coding guidelines, a problem counts as addressed when you evaluate or treat it at the encounter². "Followed by cardiology," with no assessment or care coordination from you, doesn't count.

For each problem, give your impression, its status and the findings behind it. Judge status against the patient's goal: the AMA's definitions say a patient who is not at their treatment goal is not stable², even if nothing has changed. When the diagnosis is uncertain, name the possibilities you're weighing and what will tell them apart.

Write the plan under the problem it serves. Give each medication change as drug, dose, route, frequency and reason, and each referral the question you want answered. End with when the patient should return. A referral letter carries that question to the specialist, and a patient education handout puts your advice in plain words.

Spell out anything that could be misread. The Institute for Safe Medication Practices lists abbreviations and dose notations misinterpreted in harmful or potentially harmful medication errors⁵. Write "daily," not "QD"; "units," not "U"; and the full drug name, not "MS." Write 1 mg, not 1.0 mg, and 0.5 mg, not .5 mg, since a missed decimal point turns them into 10 mg and 5 mg.

The assessment and plan support the billing level. For most visit types, CMS says, the level now rests on medical decision making or time¹, not on how much history and exam you record. The AMA's guidelines rate decision making on three elements: the problems addressed, the data reviewed or ordered, and the risk of the tests and treatments chosen or considered. If you bill by time, CMS asks for the total time or the start and stop times.

Finish the note while the visit is fresh. CMS asks clinicians to document services during the encounter or as soon as possible afterward¹ to keep the record accurate. Record work often spills into the evening. In a 2016 study of 57 US physicians, the 21 who kept diaries reported 1 to 2 hours of after-hours work each night, mostly on the electronic record⁶.

If you remember something after signing, add a dated addendum instead of rewriting the note. Medicare's Program Integrity Manual says the date and author of any amendment, correction or delayed entry should be identifiable⁷, with the change clearly and permanently marked.

To start from notes you already have, paste them into the tool at the top of this page. It sorts them into the four parts, adds no clinical details you didn't write, and lists any gaps above the note.