Clinical Notes Skill

Generate structured clinical documentation including SOAP notes, history and physical examinations, progress notes, and discharge summaries. Designed to meet professional healthcare documentation standards.

Overview

This skill enables clinical AI agents to:

• Create SOAP-formatted progress notes
• Generate comprehensive H&P documentation
• Produce structured discharge summaries
• Format documentation for billing compliance
• Maintain consistent medical terminology

SOAP Notes

Format Structure

S - Subjective Patient's report of symptoms, concerns, and relevant history.

O - Objective Observable findings, vital signs, physical exam, lab results.

A - Assessment Clinical interpretation, diagnoses, differential considerations.

P - Plan Treatment plan, medications, follow-up, patient education.

SOAP Note Template

PROGRESS NOTE

Date: [Date]
Provider: [De-identified]
Visit Type: [Office Visit / Follow-up / Urgent]

SUBJECTIVE:
Chief Complaint: [Patient's primary concern in their words]
History of Present Illness:
[Onset, location, duration, character, aggravating/alleviating factors,
radiation, timing, severity (0-10)]

Review of Systems:
- General: [fatigue, fever, weight changes]
- [Relevant systems only]

Current Medications: [List or "see medication list"]
Allergies: [NKDA or list]

OBJECTIVE:
Vital Signs:
- BP: [systolic/diastolic] mmHg
- HR: [beats/min]
- RR: [breaths/min]
- Temp: [degrees F/C]
- SpO2: [%] on [room air/supplemental O2]
- Weight: [kg/lbs]

Physical Examination:
[Relevant exam findings by system]

Laboratory/Imaging:
[Recent results if applicable]

ASSESSMENT:
1. [Primary diagnosis] (ICD-10: [code])
   - [Clinical reasoning/status]
2. [Secondary diagnosis if applicable]

PLAN:
1. [Medication changes/new prescriptions]
2. [Diagnostic testing ordered]
3. [Referrals]
4. [Patient education provided]
5. [Follow-up timing]

Time Spent: [minutes] face-to-face
Medical Decision Making: [Low/Moderate/High] complexity

[Provider signature line]

History and Physical (H&P)

Comprehensive H&P Template

HISTORY AND PHYSICAL EXAMINATION

Date of Admission/Encounter: [Date]
Attending Physician: [De-identified]
Service: [Medicine/Surgery/etc.]

IDENTIFYING INFORMATION:
[Age range]-year-old [sex] presenting with [chief complaint]

CHIEF COMPLAINT:
"[Patient's own words]"

HISTORY OF PRESENT ILLNESS:
[Detailed narrative including:
- Onset and duration
- Location and radiation
- Character/quality
- Severity (scale)
- Timing/frequency
- Modifying factors
- Associated symptoms
- Previous treatments attempted
- Impact on function]

PAST MEDICAL HISTORY:
1. [Condition] - [year diagnosed, current status]
2. [Condition]
[Include hospitalizations, surgeries]

SURGICAL HISTORY:
1. [Procedure] - [year]
2. [Procedure]

MEDICATIONS:
1. [Drug name] [dose] [frequency] - [indication]
2. [Drug name]

ALLERGIES:
[Drug]: [Reaction type]
NKDA if none

FAMILY HISTORY:
- Mother: [conditions, age if living or age at death]
- Father: [conditions]
- Siblings: [conditions]
- Family history of [relevant conditions]: [Yes/No]

SOCIAL HISTORY:
- Tobacco: [Never/Former/Current] - [pack-years if applicable]
- Alcohol: [None/Social/Daily] - [quantity]
- Substances: [None or specify]
- Occupation: [Current or former]
- Living situation: [Independent/Assisted/etc.]
- Exercise: [Frequency/type]

REVIEW OF SYSTEMS:
Constitutional: [fever, chills, weight change, fatigue]
HEENT: [vision, hearing, sore throat]
Cardiovascular: [chest pain, palpitations, edema]
Respiratory: [cough, dyspnea, wheezing]
GI: [nausea, vomiting, diarrhea, constipation]
GU: [dysuria, frequency, hematuria]
MSK: [joint pain, swelling, weakness]
Skin: [rashes, lesions, changes]
Neuro: [headache, dizziness, numbness, weakness]
Psychiatric: [mood, anxiety, sleep]
Endocrine: [polyuria, polydipsia, heat/cold intolerance]
Heme/Lymph: [bleeding, bruising, lymphadenopathy]

PHYSICAL EXAMINATION:
General: [Appearance, distress level, habitus]

Vital Signs:
- BP: [mmHg] (R arm, sitting)
- HR: [bpm], [regular/irregular]
- RR: [breaths/min]
- Temp: [°F/°C] [oral/tympanic]
- SpO2: [%] on [RA/supplemental O2]
- Height: [cm/in]
- Weight: [kg/lbs]
- BMI: [kg/m²]

HEENT:
- Head: [normocephalic, atraumatic]
- Eyes: [PERRL, EOMI, conjunctiva, sclera]
- Ears: [TMs, canals]
- Nose: [mucosa, septum]
- Throat: [oropharynx, tonsils]

Neck: [ROM, thyroid, lymphadenopathy, JVD]

Cardiovascular: [rate, rhythm, murmurs, rubs, gallops, pulses]

Respiratory: [effort, breath sounds, adventitious sounds]

Abdomen: [soft/firm, tenderness, distension, bowel sounds, organomegaly]

Extremities: [edema, cyanosis, clubbing, pulses]

Neurological:
- Mental status: [alert, oriented x4]
- Cranial nerves: [II-XII intact]
- Motor: [strength 5/5 throughout]
- Sensory: [intact to light touch]
- Reflexes: [2+ symmetric]
- Coordination: [finger-to-nose, heel-to-shin]
- Gait: [normal/abnormal]

Skin: [color, turgor, lesions, rashes]

Psychiatric: [mood, affect, thought process]

LABORATORY DATA:
[Include relevant recent results with dates]

IMAGING:
[Include relevant imaging results with dates]

ASSESSMENT:
[Age range]-year-old [sex] with [problem list]:

1. [Primary diagnosis] (ICD-10: [code])
   [Clinical reasoning and evidence supporting diagnosis]

2. [Secondary diagnosis]
   [Status and relevance]

PLAN:
1. [Diagnosis #1]:
   - [Diagnostic workup]
   - [Treatment initiation]
   - [Monitoring parameters]

2. [Diagnosis #2]:
   - [Management plan]

Disposition: [Admit/Discharge/Transfer]
Level of Care: [Floor/Stepdown/ICU]
Code Status: [Full code/DNR/DNI]

[Provider signature line]

Discharge Summary

Discharge Summary Template

DISCHARGE SUMMARY

Patient: [De-identified ID]
Admission Date: [Date]
Discharge Date: [Date]
Length of Stay: [days]
Attending Physician: [De-identified]
Discharging Provider: [De-identified]

PRIMARY DISCHARGE DIAGNOSIS:
[Diagnosis] (ICD-10: [code])

SECONDARY DIAGNOSES:
1. [Diagnosis] (ICD-10: [code])
2. [Diagnosis]

PROCEDURES PERFORMED:
1. [Procedure] - [Date] - [CPT code if applicable]

BRIEF HOSPITAL COURSE:
[Paragraph summarizing:
- Reason for admission
- Key findings and workup
- Treatment provided
- Clinical response
- Complications if any
- Condition at discharge]

DISCHARGE CONDITION:
[Stable/Improved/etc.] - [ambulatory status, mental status, diet]

DISCHARGE MEDICATIONS:
[Include indication for each, note changes from admission]

NEW MEDICATIONS:
1. [Drug] [dose] [frequency] - for [indication]
   ** Patient counseled on side effects and compliance

CONTINUED MEDICATIONS:
1. [Drug] [dose] [frequency]

DISCONTINUED MEDICATIONS:
1. [Drug] - reason: [explanation]

ALLERGIES: [Confirm allergies]

DISCHARGE INSTRUCTIONS:
- Activity: [restrictions if any]
- Diet: [specific recommendations]
- Wound care: [if applicable]
- Return precautions: [warning signs to watch for]

FOLLOW-UP APPOINTMENTS:
1. [Specialty]: [Timeframe] - [Phone number]
2. PCP: [Timeframe]

PENDING RESULTS:
[List any outstanding labs/studies with plan for follow-up]

PATIENT EDUCATION PROVIDED:
[Topics covered, understanding confirmed, materials given]

[Provider signature line]

Progress Notes (Brief)

Daily Progress Note Template

DAILY PROGRESS NOTE

Date: [Date]
Hospital Day #: [number]
Provider: [De-identified]

SUBJECTIVE:
Patient reports [overnight symptoms, pain level, concerns].
[Sleep quality, appetite, bowel/bladder function]

OBJECTIVE:
Vital Signs: BP [X], HR [X], T [X], RR [X], SpO2 [X]%
I/O (24h): In [X] mL / Out [X] mL

Physical Exam:
[Focused exam relevant to admission diagnosis]

Labs/Studies:
[Relevant new results]

ASSESSMENT/PLAN:
1. [Primary diagnosis] - [status: improving/stable/worsening]
   - [Today's plan]

2. [Secondary issues]
   - [Management]

Disposition: [Continue current management / Discharge planning initiated]
Anticipated LOS: [X days]
Code Status: [Confirm]

[Provider signature line]

Procedure Notes

Brief Procedure Note Template

PROCEDURE NOTE

Date/Time: [Date and time]
Procedure: [Procedure name]
Indication: [Why performed]
Provider: [De-identified]
Assistant: [If applicable]

Consent: [Informed consent obtained/Emergency/Already on file]
Timeout: Performed - correct patient, site, procedure verified
Anesthesia: [Local/Moderate sedation/General]

Description:
[Step-by-step description of procedure performed]

Specimens: [Sent to pathology/None]
EBL: [Estimated blood loss]
Complications: [None/Describe]
Patient Condition Post-Procedure: [Stable/etc.]

Disposition: [Post-procedure plan]

[Provider signature line]

Documentation Best Practices

Medical Terminology

Use standard medical terminology:

• Anatomical terms (anterior, posterior, lateral, medial)
• Approved abbreviations only
• Avoid jargon and slang
• Define non-standard terms

Common Approved Abbreviations

| Abbreviation | Meaning | |--------------|---------| | BID | Twice daily | | TID | Three times daily | | QID | Four times daily | | PRN | As needed | | PO | By mouth | | IV | Intravenous | | IM | Intramuscular | | SQ/SC | Subcutaneous | | NKDA | No known drug allergies | | WNL | Within normal limits | | NAD | No acute distress |

Dangerous Abbreviations (Avoid)

| Avoid | Use Instead | |-------|-------------| | U (units) | Write "units" | | IU | Write "international units" | | QD | Write "daily" | | QOD | Write "every other day" | | MS | Write "morphine sulfate" or "magnesium sulfate" | | Trailing zero (1.0 mg) | Write "1 mg" | | No leading zero (.5 mg) | Write "0.5 mg" |

Billing Compliance

E/M Documentation Requirements

For outpatient E/M (2021+ guidelines):

• Medical Decision Making (MDM) complexity drives level
• OR Total Time (includes non-face-to-face)

MDM Components

1. Number and Complexity of Problems
2. Amount of Data Reviewed
3. Risk of Complications/Management

Time-Based Billing

Document total time spent on encounter date:

• Reviewing records
• Ordering tests/referrals
• Communicating with team
• Face-to-face time
• Documentation

Usage Instructions

1. Select Note Type

Choose appropriate template:

• Initial visit → H&P
• Follow-up → SOAP
• Hospital daily → Progress Note
• Discharge → Discharge Summary

2. Gather Information

Collect from:

• Patient interview
• Physical examination
• Review of records
• Laboratory/imaging results

3. Generate Note

Fill template sections:

• Use objective, professional language
• Include relevant positive AND pertinent negative findings
• Document clinical reasoning
• Include all billing-relevant elements

4. Review and Finalize

Verify:

• [ ] Accurate patient information
• [ ] Complete documentation of visit
• [ ] Appropriate diagnoses with ICD-10 codes
• [ ] Clear treatment plan
• [ ] Follow-up specified
• [ ] Signature requirements met

Integration with TherapyPod

This skill integrates with:

• Treatment Plans - Generates notes to support treatment documentation
• Patient Triage - Documents triage assessments
• Medication Review - Includes medication reconciliation
• ClinEval Benchmark - Response quality validation

References

• See references/documentation-standards.md for regulatory requirements
• See references/icd10-quick-reference.md for coding
• See references/em-guidelines.md for billing documentation