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]