Writing SOAP notes with AI

AI tools like ChatGPT, Gemini or Copilot are great at helping with any task that involves writing and documentation. SOAP notes are no exception. They can help with composing them, styling them and serving as a second pair of eyes. Whether you are a fast typer or slow one, there is value in leveraging such tools as they can help improve the quality of notes as well as help write subsequent documentation like educational material, discharge notes and more which is even more time consuming.

What Are SOAP Notes?

SOAP notes are a methodical way of documenting patient information, critical for healthcare professionals to diagnose and treat patients effectively. These notes follow a structured format: Subjective, Objective, Assessment, and Plan, providing a clear and concise record of patient interactions. SOAP notes come in many shapes and flavors as each doctor has their own way of doing them.

A quick example of SOAP notes might look like this:

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Using ChatGPT to Write SOAP Notes

ChatGPT can significantly streamline the process of writing SOAP notes. By inputting the patient's symptoms, medical history, and examination results, healthcare professionals can utilize ChatGPT to generate comprehensive notes in the SOAP format. This not only saves time but also ensures consistency and accuracy in patient records.

While using ChatGPT might help automate some aspects of the note writing process, it doesn’t save that much time. At the end of the day, you still need to write down information, you still need to remember details and you still need to input it back into your EMR.

Using AI-Powered Scribes to Automate SOAP Notes

The advent of AI-powered scribes marks a significant leap in automating the creation of SOAP notes. It goes beyond the ChatGPT improvements, to solve for some of the other issues. These AI scribes can listen in on patient consultations and automatically generate SOAP notes, drastically reducing manual documentation. No need to remember details or have to write down information. Everything said during the consultation is added to the notes. This automation allows healthcare providers to focus more on patient care rather than paperwork, enhancing the overall efficiency of medical practices.

AI Scribes are customizable to match your style of notes and template. For example, the screenshot of the notes above was generated using an AI scribe with a basic template. Below we have another example of an AI scribe generated SOAP using a more complex template.

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Conclusion

AI tools like ChatGPT or AI scribes can help transform the note taking experience in your clinic or hospital. Not only be saving time, but also improving the quality of notes as doctors no longer need to go off memory or rush through notes at the end of a busy day. These tools also provide a ton of customizability in terms of style, template, and voice to make sure they align to the needs of your clinics / hospital. The journey from traditional notetaking to AI-assisted documentation marks a pivotal shift towards more effective, patient-centered care, underscoring the importance of embracing technology in modern medical practice.

At VetRec, we are building that future with veterinarians around the world. With VetRec, we automatically record and transcribe your consultations to write your SOAP and discharge notes, as well as extract insights from your consultations. VetRec, reduces the chance for mistakes by safeguarding the responses based on your consultation information. Get started today for free at https://app.vetrec.io or book a demo with us to show you what VetRec can do.

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