Generate complete SOAP note from patient visit
AI asks about symptoms and exam findings, then writes a professional SOAP note ready to paste into your EHR.
Generate complete SOAP note from patient visit
River's SOAP Note Generator creates complete, professional SOAP notes from patient visit information. You provide chief complaint, history of present illness, review of systems, physical exam findings, assessment, and plan, and the AI writes a comprehensive SOAP note in proper clinical format. The note includes all required sections with appropriate medical terminology, logical organization, and documentation standards. Perfect for physicians, residents, and medical students who need efficient, high-quality clinical documentation.
Unlike struggling with documentation after long clinic days, this AI structures your clinical information into properly formatted SOAP notes. The tool asks targeted questions about each SOAP component, then generates professional documentation that meets medical record requirements. The note maintains clinical accuracy while saving documentation time. You focus on patient care during the visit, capture key information, then let the AI format it into comprehensive note ready for your electronic health record.
This tool is perfect for attending physicians documenting outpatient visits, medical residents managing high patient volumes, medical students learning proper documentation, or any clinician who needs to create SOAP notes efficiently. If documentation takes too long after clinic, or if you want to ensure complete, well-organized clinical notes, this creates the professional SOAP documentation you need. Use it for any outpatient encounter requiring SOAP format documentation.
What Makes Clinical Documentation Effective
Effective clinical documentation serves multiple purposes: clear communication with other providers, legal protection, quality measurement, and billing justification. Weak documentation is vague (patient feels better), lacks specificity about severity or duration, or omits key clinical reasoning. Strong documentation is specific (chest pain 7/10, substernal, non-radiating, onset 2 hours ago), includes pertinent positives and negatives, documents medical decision-making, and supports level of service billed. The note should tell story of encounter so any provider reading it understands what happened and why you made specific decisions.
The SOAP format (Subjective, Objective, Assessment, Plan) provides logical structure for clinical encounters. Subjective captures patient's description of symptoms and concerns. Objective documents measurable findings from exam, vitals, and tests. Assessment synthesizes information into diagnosis or clinical impression with supporting reasoning. Plan outlines next steps including medications, tests, referrals, and follow-up. Each section serves specific purpose. Strong SOAP notes flow logically, include relevant details while omitting unnecessary information, and document thought process behind clinical decisions.
Complete documentation requires specific elements: chief complaint, HPI with relevant history, pertinent ROS, vital signs, focused physical exam, assessment with differential if applicable, detailed plan, and patient education provided. For billing purposes, documentation must support medical necessity and complexity of visit. Include severity of symptoms, review of relevant history, pertinent exam findings showing medical decision-making, and clear plan addressing patient concerns. When documentation is thorough and well-organized, it protects providers legally, facilitates quality care coordination, and supports appropriate reimbursement.
What You Get
Complete SOAP note with all required sections
Professional medical terminology and format
Subjective section with HPI and ROS
Objective section with vitals and exam findings
Assessment with clinical reasoning
Detailed plan with medications, tests, and follow-up
How It Works
- 1Provide visit informationAI asks about chief complaint, history, exam findings, and plan
- 2AI writes SOAP noteGenerates complete, properly formatted SOAP note in 5-10 minutes
- 3Review and editVerify accuracy, add specific details, ensure completeness
- 4Copy to EHRPaste into your electronic health record system
Frequently Asked Questions
Does this meet documentation requirements for billing?
The AI creates clinically appropriate SOAP notes with proper structure and content. However, you must ensure the final note accurately reflects the encounter, includes all required elements for the level of service you're billing, and meets your institution's documentation standards. Review and customize as needed to support medical necessity and visit complexity. The AI provides solid foundation, but you're responsible for ensuring documentation completeness and accuracy for billing purposes.
Can I use this for inpatient progress notes?
This tool is optimized for SOAP-format outpatient notes. For inpatient progress notes, you may need different format (some institutions use SOAP, others use different structures). The tool can be adapted, but ensure output matches your hospital's documentation requirements. For admission notes, discharge summaries, or procedure notes, other specialized tools may be more appropriate.
How specific should I be when providing information?
Be as specific as possible. For HPI, include onset, duration, severity, quality, location, modifying factors, and associated symptoms. For exam, include specific findings (not just normal or abnormal). The more detail you provide, the more complete and accurate the note. If you give vague information, the note will be generic. Your clinical judgment and specific observations make the note valuable and defensible.
Will this work with my EHR system?
The AI generates text that you copy and paste into your EHR. It works with any system that accepts text input (Epic, Cerner, Athena, etc.). The note is formatted as plain text with clear sections. You may need to adjust formatting slightly based on your EHR's specific structure, but the content and organization transfer to any system. Some EHRs have specific templates or required fields, adjust as needed for your system.
Can I save templates for common visit types?
You can reuse the structure for similar visits. For example, if you see many patients with diabetes follow-up, you might note the HPI structure, ROS elements, exam components, and plan elements that typically apply. The AI generates fresh notes each time, but having your standard approach helps you provide consistent information quickly. Some clinicians create personal templates or checklists of what to include for common visit types.
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