SOAP Note Skill

Good clinical documentation is structured so the next clinician can reconstruct the reasoning in seconds: what the patient reported, what was found, what you think, and what you'll do. This skill turns encounter notes into a clean SOAP note that follows that structure and keeps assessment separate from plan.

Clinical-safety note: this is a documentation-formatting aid, not medical advice or a diagnosis. It organises information a qualified clinician provides; all content must be reviewed and verified by the treating clinician before entering the medical record. Do not invent clinical findings, vitals, or results.

Working from a brief

Given rough encounter notes, produce the full structured note anyway — organise what's given into the four sections and place each detail correctly. Where a standard field wasn't provided, leave it clearly marked (e.g. "Vitals: not documented") rather than inventing a value. Never fabricate findings, labs, or measurements.

Required Inputs

Ask for these only if they aren't already provided (else mark as not documented):