Acute Visit SOAP Note

(Write in medical shorthand with extensive use of abbreviations where possible. Use bullet points instead of prose, paragraph or narrative style. Quotes can be given as supporting information in all sections except the summary. Ensure output is concise throughout.) **Summary:** [Concise problem list summarising the clinical encounter with an inline assessment and plan for each issue discussed] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Use clinical reasoning to summarise each problem. Write as a numbered list with each item on a new line. Format each item as: problem – assessment and plan. Use abbreviations and shorthand throughout. Be ultra-concise.) **Subjective:** [Reason for visit or presenting complaint including a duration indicator for each item] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. If items are listed in the Subjective section of contextual notes, include only those items and group all relevant information under them. Summarise symptom groups as syndromes where identified. Write as a numbered list with bulleted child items beneath each parent item. Always include a duration indicator for each item.) [All relevant subjective information for each consultation reason including symptom characteristics, duration, modifiers, associated symptoms, relevant past medical and surgical history, social factors and current medications] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write as indented child bullet points beneath the relevant numbered parent item. One item per bullet point. If items are related, combine them into a single bullet point.) **Objective:** [Vitals including blood pressure, pulse rate, temperature, body mass index and oxygen saturation] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write inline in the following format: BP=[blood pressure] | PR=[pulse rate] | T=[temperature] | BMI=[body mass index] | Sats=[oxygen saturation].) <u>[Relevant body system heading]</u> (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Use the following abbreviations for system headings: ENT for ear, nose and throat findings; Resp for respiratory findings; CVS for cardiovascular findings; Neuro for neurological findings; Abdomen for abdominal and gastrointestinal findings; Skin for dermatological findings; MSK for musculoskeletal findings. Omit any system heading that has no relevant findings.) [indent] [Clinical finding or sign per body system] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Write each finding as an indented bullet point beneath the relevant body system heading. Precede each finding with the appropriate symbol: print ⊕ if the finding is present and clinically relevant; print ⊖ if explicitly noted as absent and clinically relevant; print - if normal. Use shorthand and abbreviations throughout.) <u>[Completed investigations with available results]</u> (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. List only completed investigations with available results. Do not include investigations that are planned or pending. Write as a bullet point list.) **Assessment:** [Clinician's explicitly stated confirmed diagnoses, syndromes or symptom clusters with inline assessment for each] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Never invent or infer a diagnosis. If diagnoses are listed in the contextual notes under the Assessment section, use those diagnoses only. Write as a numbered list formatted as "1)". State one diagnosis per line. Follow each diagnosis with a dash and then any further classification, differential, impression or assessment inline.) **Plan:** [Treatment, therapy, intervention, administrative task, referral and follow-up details] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely. Do not list scripted medications except when describing medication changes or providing special instructions. Combine related plan items into a single line where logical. Write as a bullet point list using abbreviations and shorthand throughout.)