SOAP Note Generator

When to Use This Skill

Use when a clinician needs a structured Subjective-Objective-Assessment-Plan note generated from FHIR encounter data.

Clinical Workflow

1. Use fhir_read or fhir_search to retrieve the Encounter (reasonCode for chief complaint, class for setting, period, participant for provider)
2. Use fhir_read to retrieve Patient demographics for note header
3. Use fhir_search to pull vital signs (Observation category=vital-signs) during the encounter window
4. Use fhir_search to pull laboratory results (Observation category=laboratory) from encounter date
5. Use fhir_search to pull active MedicationRequest resources; separate pre-existing from new prescriptions by authoredOn
6. Use fhir_search to pull Condition resources for encounter diagnoses and active problem list
7. Use fhir_search to pull Procedure resources performed during the encounter
8. Use fhir_search to pull active AllergyIntolerance for allergy list
9. Assemble SOAP note with setting-appropriate format (AMB, EMER, IMP)
10. Optionally use fhir_create to persist as DocumentReference (LOINC 11506-3 for progress note)

FHIR Resources

• Encounter -- Visit context: class, type, reasonCode, period, participant
• Patient -- Demographics for note header
• Observation -- Vitals (category=vital-signs) and labs (category=laboratory)
• MedicationRequest -- Current medications and new prescriptions
• Condition -- Encounter diagnoses and active problems (ICD-10 codes)
• Procedure -- Procedures performed during visit
• AllergyIntolerance -- Allergy list
• DocumentReference -- Output: persisted note

FHIR Query Examples

Pull Encounter

fhir_search(resourceType="Encounter", queryParams="patient=[patient-id]&date=[YYYY-MM-DD]&_sort=-date&_count=1")

Pull Encounter Vitals

fhir_search(resourceType="Observation", queryParams="patient=[patient-id]&category=vital-signs&date=ge[encounter-start]&date=le[encounter-end]&_sort=-date")

Pull Encounter Diagnoses

fhir_search(resourceType="Condition", queryParams="patient=[patient-id]&encounter=[encounter-id]")

Clinical Guidelines

• CMS E/M documentation guidelines (2021 revision: focus on medical decision-making)
• Specialty-specific documentation requirements
• LOINC document type codes: 11506-3 (progress note), 34111-5 (ED note), 34117-2 (H&P note)

Interpretation Guide

• Subjective: chief complaint from Encounter.reasonCode, current medications, allergies. HPI synthesized from encounter reason and active conditions relevant to the visit
• Objective: vitals in standard format (T/HR/RR/BP/SpO2/Wt/Ht/BMI), labs grouped by panel with abnormals flagged, physical exam findings from Observations with category=exam if available
• Assessment: numbered problem list with ICD-10 codes from encounter Conditions
• Plan: per-problem actions including medication changes, referrals, follow-up timeline, procedures performed
• For ED encounters: add triage acuity, time-stamped reassessments, disposition
• For inpatient encounters: add hospital day number, consults, anticipated discharge

Safety

• Never fabricate clinical data -- only report what FHIR returns
• Flag critical/abnormal values immediately
• Scope all FHIR queries to the authenticated patient
• Use standard terminology (LOINC, SNOMED CT, RxNorm, ICD-10)
• Present data in clinician-friendly format with reference ranges