SOAP Note Assistant

Educational clinical decision support for physicians, pharmacists, and students. Drafts are AI-assisted and can be wrong — a qualified clinician must verify every problem, dose, and citation before it informs patient care. Enter de-identified information only.

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Subjective

Patient-reported and explicitly supplied information.

Chief concern Symptoms one per line History Adherence / patient concerns Explicitly supplied problems one per line Patient-reported concerns one per line

Complete history and patient context

Patient description HPI timing / onset Symptom course Associated symptoms one per line Pertinent negatives one per line Aggravating factors one per line Relieving factors one per line Review of systems system: finding, one per line Past medical history one per line Surgical history one per line Family history one per line Social history one per line Diet and nutrition Functional status Patient goals one per line

Objective

Medicines, allergies, measurements, labs, and findings.

Medications

Allergy review status Allergies one per line Documented findings one per line

OObjective measurements and calculations

Only supplied values are used. Blank fields are not treated as normal.

Age Height (cm) Weight (kg) CG sex factor eGFR Serum creatinine INR Potassium Magnesium (mg/dL) QTc (ms) Heart rate Digoxin level CBC / hemoglobin

Vital signs (label: value, one per line) Labs (label: value, one per line)

OComplete examination, diagnostics, and renal context

Record actual findings and trends. This supports AKI vs CKD vs AKI on CKD reasoning without assuming a diagnosis.

Physical examination one finding per line Laboratory results with date/time one per line Other diagnostic results one per line Imaging results one per line Microbiology results one per line

Systolic BPDiastolic BP Respiratory rateTemperature °C Oxygen saturation %Pain score /10 SodiumBicarbonate BUNTotal calcium (mg/dL) GlucoseHbA1c % WBCPlatelets Albumin (g/dL)AST ALTBilirubin Creatinine 48 h agoCreatinine 7 d ago eGFR ≥3 months agoUACR mg/g Urine output mL/kg/hUrine output duration h

Kidney abnormality documented for at least 3 months Receiving dialysis Volume status / intake-output context Recent nephrotoxic or hemodynamic exposures one per line Liver status Warfarin indication DVT/VTE timing Aspirin/clopidogrel indication

A/PClinical reasoning, plan, and follow-up

Keep established diagnoses separate from differential considerations and unresolved questions.

Clinician assessment one problem per line Differential considerations one per line Goals of therapy one goal per line; link to the problem Pharmacological therapy one action per line Other clinician plan one action per line Lifestyle / non-pharmacological plan one action per line Monitoring plan one per line Counseling / shared decisions one per line Follow-up one per line Return precautions one per line Referrals / consultations one per line Preventive care one per line

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Draft workspaceVerified information will be organized into these four sections.

SSubjectiveSymptoms and patient history

OObjectiveVitals, labs, and findings

AAssessmentProblems for clinician review

PPlanDocumented actions and follow-up