We all know that clinic notes are necessary, but they are also a major time sink: Clinicians spend an average of 2.5 hours writing notes each day.
Let’s liven things up and make perfecting your SOAP notes more fun than a birthday at a trampoline park. Our step-by-step guide will have you writing clinic notes way faster so you can get back your time — and your life outside your job.
We’ll cover:
- What are clinic notes?
- Why are they important?
- The SOAP method for writing clinic notes
- How clinic notes differ in each specialty
- Best practices and tips for improving note-taking
- How to speed up clinical notes with Lindy, the cutting-edge AI medical scribe
Let’s get started!
What are clinic notes?
Clinic notes, or SOAP notes, are what doctors, nurses, and other healthcare professionals write to document interactions with patients. They contain information like symptoms, diagnoses, and treatment plans.
Why are clinic notes important?
Here are the main reasons why you should be properly documenting patient encounters:
- Helps provide continuity of care. When patients see multiple doctors or switch healthcare systems, notes allow new providers to quickly get up to speed on their medical history and current issues. No need to start from scratch at each appointment!
- A huge way of mitigating risk. If there's ever a dispute over treatment, notes serve as a legal record of what transpired. They also help make sure important details aren't forgotten or miscommunicated between staff.
- A great way to keep yourself organized. Trying to remember everything discussed with dozens of patients each week isn't just unrealistic; it's impossible! Notes are your secret weapon for staying on top of who needs follow-ups, lab results, referrals, or anything else.
- They help you spot those pesky patterns. Ever noticed a patient always comes in with a headache after a stressful week? Notes help connect the dots, revealing underlying issues and leading to better treatment plans.
- Notes streamline teamwork. They function as the essential communication hub for everyone involved in a patient's care, ensuring no one misses a beat.
The SOAP method: A step-by-step guide to writing clinic notes
The SOAP method offers a clear and organized system for documenting patient encounters. It's like a cheat sheet for crafting concise yet comprehensive notes.
Let's break it down step-by-step and quickly turn you into a SOAP expert:
1. Subjective
This is where you record what the patient told you about why they’re visiting. Get the full scoop on their symptoms, medical history, and concerns. Don’t be afraid to ask tons of questions — your patient will thank you for being thorough. But do be succinct.
2. Objective
Now comes the up-close-and-personal part: The exam. Note the patient’s vital signs and any exam findings. Describe what you see, hear, and perceive. Leave out your own personal judgments — just stick to the cold, hard facts. Measurements, vital signs, physical findings...you know the drill. Get gloving!
3. Assessment
Here’s where you get to flex those diagnostic muscles. Review the information from the subjective and objective sections and determine a diagnosis or differential diagnoses to consider. Explain your rationale and clinical reasoning for how you reached your conclusions. If you need further testing, now’s the time to order it.
4. Plan
Last but not least, lay out your treatment plan. Discuss prognosis, recommendations, follow-up, referrals, and anything else needed to properly care for your patient.
Be specific — don’t just put “RTC PRN.” Patients will thank you for clear directions on what to do next.
And with that, your SOAP note is squeaky clean. Happy charting, doc!
Clinic note specifics for different healthcare professions
Clinic notes hold a wealth of information, but the key details vary depending on the healthcare profession. Understanding these differences can help you efficiently navigate patient records.
Here's a deeper look at what SOAP notes tend to emphasize for each specialty:
Physician:
- Subjective: Chief complaint, history of present illness, relevant medical history, allergies, medications.
- Objective: Vital signs, physical exam findings, relevant lab or imaging results.
- Assessment: Diagnosis or differential diagnoses.
- Plan: Treatment recommendations, including medications, procedures, referrals, and patient education.
Psychiatrist:
- Subjective: Patient's self-reported mood, thoughts, behaviors, and any relevant stressors.
- Objective: Mental status exam observations (appearance, affect, speech patterns, thought content).
- Assessment: Diagnosis, including any relevant specifiers (severity, duration).
- Plan: Treatment approach (medication, therapy modalities), safety assessment, and follow-up plans.
- Subjective: Patient's pain complaints (location, severity, quality), relevant history, aggravating/alleviating factors.
- Objective: Posture assessment, spinal exam (palpation, range of motion), neurological and orthopedic tests.
- Assessment: Diagnosis, subluxations, and other identified musculoskeletal issues.
- Plan: Adjustment techniques, modalities, exercises, and recommendations for self-care.
- Subjective: Patient's functional limitations, pain levels, and progress since the previous session.
- Objective: Reassessment of strength, range of motion, functional tests, and pain response to treatment.
- Assessment: Progress assessment, any modifications needed to the treatment plan.
- Plan: Exercise prescription, manual therapy techniques, modalities used, and goals for the next session.
Others:
- Dentist: SOAP notes cover oral exams (teeth, gums, soft tissues), X-ray findings, diagnoses (cavities, periodontal disease), procedures (fillings, cleanings), and recommendations for at-home care.
- Ophthalmologist: Centered on vision assessments (visual acuity, refraction, eye pressure), eye health exams (dilated fundus exam), diagnoses of eye conditions, prescriptions (glasses, contacts), and any performed procedures.
- Cardiologist: SOAP notes detail heart health assessments, including cardiac exam (heart sounds, murmurs), results of tests like EKG, echocardiogram, stress tests, diagnoses of cardiovascular conditions, and treatment plans (medication, lifestyle changes, procedures).
Best practices and tips for improving your notes
Even the most experienced clinicians struggle with clinic notes at times. The good news is, with a few best practices, you’ll be churning them out like pizzas.
- Keep it brief. We know, there’s a lot to say. But resist the urge to include every detail of each visit. Focus on the highlights and key findings. Be thorough but brief.
- Use templates. Save yourself time by creating templates for common visits. Have one for physicals, med checks, procedures, etc. Fill in the blanks, and you’re done. Just be sure to customize as needed for each patient. We don’t want a “one-size-fits-all” approach here!
- Proofread. Typos and grammar mistakes reflect poorly on you and your practice. Double-check your notes for any errors before signing off. If time is tight, at least give them a quick once-over. Your colleagues and reviewers will appreciate your attention to detail.
- Stay organized. Structure your notes in a logical manner using headings and bullet points. This makes your notes easy to follow and key information quick to find. Include the essential SOAP elements in the proper order. Your notes will look professional and polished.
How to speed up clinical notes with Lindy
Still writing down notes like it’s 1887? No bueno!
Lindy is the top medical scribe, designed to make clinical notes a breeze (instead of a major drain).
Here’s how Lindy can upgrade your clinic notes:
- Lightning-fast note creation: Lindy listens intently, transforming your spoken words into 99%+ accurate, detailed clinic notes faster than you can say "stethoscope."
- Effortless EHR integration: With a single click, your notes are uploaded to your EHR (like Epic and Cerner). Lindy syncs up, even pulling in relevant patient data for a complete picture.
- A proactive ally: As you speak, Lindy's AI brain offers helpful suggestions based on your words and the patient's history. Keep what works, customize what doesn't — it's your call.
- Lindy learns your language: The more you use Lindy, the smarter it gets, adapting to your unique phrasing, abbreviations, and those niche terms you love. Got a thick accent or unique speech pattern? Not a problem.
- Never miss a follow-up: Lindy analyzes those notes and turns them into an actionable task list. It'll give you and your team gentle nudges for follow-ups, tests, referrals — you name it.
- Patient data protection: Security is top of mind. Lindy adheres strictly to HIPAA, PIPEDA, and other privacy regulations, keeping sensitive information under lock and key.
- Reclaim precious hours: Imagine slashing your note-taking time by 80%! That's potentially hours of your day back for what matters most — actually caring for patients.
Skeptical? Give Lindy a whirl for free and discover why clinics are ditching the pen and paper.
Summing up
That was the foolproof guide to crafting clinic notes that'll help you tip the scales favorably when it comes to a work/life balance.
Just remember SOAP (and we’re not talking the shower kind), and make use of shortcuts like templates and high-level AI with speech recognition (thanks, Lindy!) to crank those babies out in record time. You’ve got this!
Try out HIPAA and PIPEDA-compliant AI clinic notes for free.
