SOAP Note Generator

Overview

Generate structured SOAP (Subjective, Objective, Assessment, Plan) notes from FHIR encounter data. Pull chief complaint, history of present illness context, vital signs, laboratory results, active medications, active conditions, and procedures performed during the encounter. Support specialty-specific formatting for primary care, emergency department, and inpatient encounters. Optionally create a DocumentReference resource to persist the generated note.

FHIR Resources Used

Instructions

Step 1: Retrieve Encounter Context

Tool: fhir_read
resourceType: "Encounter"
id: "[encounter-id]"

Extract:

• Chief complaint: reasonCode[0].text or reasonCode[0].coding[0].display
• Visit type: type[0].coding[0].display (e.g., Office Visit, ED Visit, Follow-up)
• Encounter class: class.code (AMB = ambulatory, EMER = emergency, IMP = inpatient)
• Period: period.start and period.end
• Attending: participant where type.coding.code = "ATND"

If no encounter ID is provided, search by patient and date:

Tool: fhir_search
resourceType: "Encounter"
queryParams: "patient=[patient-id]&date=[YYYY-MM-DD]&_sort=-date&_count=1"

Step 2: Retrieve Patient Demographics

Tool: fhir_read
resourceType: "Patient"
id: "[patient-id]"

Extract name, DOB (calculate age), gender, MRN for note header.

Step 3: Pull Vital Signs

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

Map vital signs by LOINC code:

• 8310-5: Body temperature
• 8867-4: Heart rate
• 9279-1: Respiratory rate
• 85354-9: Blood pressure panel (components: 8480-6 systolic, 8462-4 diastolic)
• 29463-7: Body weight
• 8302-2: Body height
• 59408-5: SpO2 (pulse oximetry)
• 39156-5: BMI

Step 4: Pull Laboratory Results

Tool: fhir_search
resourceType: "Observation"
queryParams: "patient=[patient-id]&category=laboratory&date=ge[encounter-start]&_sort=-date&_count=50"

Group lab results by panel. Present abnormal values with reference ranges. Flag critical values.

Step 5: Pull Active Medications

Tool: fhir_search
resourceType: "MedicationRequest"
queryParams: "patient=[patient-id]&status=active&_count=100"

Separate into:

• Pre-existing medications: authoredOn before encounter start
• New prescriptions: authoredOn during encounter period
• Changed medications: status changes during encounter

Step 6: Pull Encounter Diagnoses and Active Conditions

6a: Encounter-specific diagnoses

Tool: fhir_search
resourceType: "Condition"
queryParams: "patient=[patient-id]&encounter=[encounter-id]"

6b: Active problem list

Tool: fhir_search
resourceType: "Condition"
queryParams: "patient=[patient-id]&clinical-status=active"

Step 7: Pull Procedures Performed

Tool: fhir_search
resourceType: "Procedure"
queryParams: "patient=[patient-id]&encounter=[encounter-id]"

Step 8: Pull Allergies

Tool: fhir_search
resourceType: "AllergyIntolerance"
queryParams: "patient=[patient-id]&clinical-status=active"

Step 9: Assemble SOAP Note

Structure the note based on encounter class:

For ambulatory (AMB) encounters:

SOAP NOTE
=========
Patient: [name] | MRN: [mrn] | DOB: [dob] (Age: [age]) | Sex: [gender]
Date: [encounter-date] | Provider: [attending]
Visit Type: [type] | Encounter: [encounter-id]

SUBJECTIVE
----------
Chief Complaint: [reasonCode text]
HPI: [Synthesize from encounter reason, active conditions relevant to visit]
ROS: [Derive from Observation resources with category=survey if available]
Current Medications: [List with dose/frequency]
Allergies: [List with reaction type]

OBJECTIVE
---------
Vitals: T [temp] | HR [hr] | RR [rr] | BP [sys]/[dia] | SpO2 [spo2]% | Wt [wt] | Ht [ht] | BMI [bmi]
[Physical exam findings from Observation category=exam if available]
Labs: [Grouped by panel, abnormals flagged]

ASSESSMENT
----------
[Numbered problem list with ICD-10 codes from Condition.code]
1. [Primary diagnosis] - [ICD-10]
2. [Secondary diagnosis] - [ICD-10]

PLAN
----
[Per problem:]
1. [Diagnosis]: [Actions - new meds, referrals, follow-up]
2. [Diagnosis]: [Actions]
Procedures Performed: [List from Step 7]
Follow-up: [From CarePlan if available]

For emergency (EMER) encounters, add: triage acuity, time-stamped reassessments, disposition.

For inpatient (IMP) encounters, add: admitting diagnosis, hospital day number, consults.

Step 10: Persist Note as DocumentReference (if authorized)

Tool: fhir_create
resourceType: "DocumentReference"
resource: {
  "resourceType": "DocumentReference",
  "status": "current",
  "type": {
    "coding": [{
      "system": "http://loinc.org",
      "code": "11506-3",
      "display": "Progress note"
    }]
  },
  "subject": {"reference": "Patient/[patient-id]"},
  "date": "[current-datetime]",
  "author": [{"reference": "Practitioner/[practitioner-id]"}],
  "content": [{
    "attachment": {
      "contentType": "text/plain",
      "data": "[base64-encoded-note]"
    }
  }],
  "context": {
    "encounter": [{"reference": "Encounter/[encounter-id]"}]
  }
}

Use LOINC codes for document type based on setting:

• 11506-3: Progress note
• 34111-5: Emergency department note
• 34117-2: History and physical note
• 18842-5: Discharge summary

Examples

Example 1: Primary Care Office Visit

User says: "Write a SOAP note for encounter ENC-5678 for patient 12345."

Actions:

1. fhir_read Encounter/ENC-5678. Returns: AMB class, type=Office Visit, reasonCode="Annual physical", period 2024-03-15T09:00 to 2024-03-15T09:30, attending=Dr. Smith.
2. fhir_read Patient/12345. Returns: John Doe, DOB 1970-05-20, Male, MRN-12345.
3. fhir_search Observation with category=vital-signs for encounter window. Returns: T 98.6, HR 72, RR 16, BP 142/88, SpO2 99%, Wt 210 lbs, Ht 70 in, BMI 30.1.
4. fhir_search Observation with category=laboratory. Returns: HbA1c 7.2%, lipid panel (TC 240, LDL 155, HDL 38, TG 235).
5. fhir_search MedicationRequest active. Returns: metformin 1000mg BID, lisinopril 10mg daily.
6. fhir_search Condition for encounter + active. Returns: encounter dx: HTN uncontrolled, T2DM. Active: HTN, T2DM, obesity.
7. fhir_search AllergyIntolerance. Returns: penicillin (rash).

Result:

SOAP NOTE
=========
Patient: John Doe | MRN: MRN-12345 | DOB: 1970-05-20 (Age: 53) | Sex: Male
Date: 2024-03-15 | Provider: Dr. Smith
Visit Type: Office Visit | Encounter: ENC-5678

SUBJECTIVE
----------
Chief Complaint: Annual physical
Current Medications: Metformin 1000mg BID, Lisinopril 10mg daily
Allergies: Penicillin (rash)

OBJECTIVE
---------
Vitals: T 98.6 | HR 72 | RR 16 | BP 142/88 | SpO2 99% | Wt 210 lbs | Ht 70 in | BMI 30.1
Labs:
  HbA1c: 7.2% [HIGH - goal <7%]
  Total Cholesterol: 240 [HIGH]
  LDL: 155 [HIGH]
  HDL: 38 [LOW]
  Triglycerides: 235 [HIGH]

ASSESSMENT
----------
1. Hypertension, uncontrolled - I10
2. Type 2 diabetes mellitus, above goal - E11.65
3. Hyperlipidemia, mixed - E78.2
4. Obesity, BMI 30.1 - E66.01

PLAN
----
1. HTN: Increase lisinopril to 20mg daily. Recheck BP in 2 weeks.
2. T2DM: Continue metformin. Reinforce dietary counseling. Recheck HbA1c in 3 months.
3. Hyperlipidemia: Start atorvastatin 20mg daily. Fasting lipid panel in 6 weeks.
4. Obesity: Discussed diet and exercise. Referral to nutrition.
Follow-up: 3 months or sooner if BP not improved at 2-week check.

Example 2: Emergency Department Visit

User says: "Generate SOAP note for the ED visit, patient ID pt-9999, today's encounter."

Actions:

1. fhir_search Encounter for patient pt-9999, today, class=EMER. Returns: encounter ENC-ED-100, reasonCode="Chest pain", period started 2024-03-15T14:22.
2. fhir_read Patient/pt-9999. Returns: Mary Johnson, DOB 1952-08-10, Female.
3. fhir_search Observation vital-signs during encounter. Returns: T 98.2, HR 92, RR 20, BP 168/95, SpO2 97%.
4. fhir_search Observation laboratory. Returns: Troponin I 0.02 (normal), BMP normal, CBC normal, D-dimer 0.3 (normal).
5. fhir_search Procedure for encounter. Returns: 12-lead ECG performed.
6. fhir_search Condition for encounter. Returns: Chest pain NOS (R07.9), HTN (I10).

Result:

SOAP NOTE - EMERGENCY DEPARTMENT
=================================
Patient: Mary Johnson | MRN: MRN-9999 | DOB: 1952-08-10 (Age: 71) | Sex: Female
Date: 2024-03-15 14:22 | Encounter: ENC-ED-100

SUBJECTIVE
----------
Chief Complaint: Chest pain
HPI: 71-year-old female presenting with substernal chest pain onset 2 hours prior.

OBJECTIVE
---------
Vitals: T 98.2 | HR 92 | RR 20 | BP 168/95 | SpO2 97%
Labs:
  Troponin I: 0.02 ng/mL [NORMAL]
  BMP: Within normal limits
  CBC: Within normal limits
  D-dimer: 0.3 mcg/mL [NORMAL]
Procedures: 12-lead ECG performed

ASSESSMENT
----------
1. Chest pain, unspecified - R07.9
2. Hypertension - I10

PLAN
----
1. Chest pain: Serial troponins q3h. Cardiology consult if troponin rises. Chest pain observation protocol.
2. HTN: Elevated in setting of pain/anxiety. Monitor.
Disposition: Observation pending serial troponins.

Troubleshooting

Encounter reasonCode is empty or missing chief complaint

• Check Encounter.type for visit type context.
• Search Condition resources linked to the encounter: fhir_search Condition with encounter=[encounter-id]. Use the primary diagnosis as a proxy for chief complaint.
• Some systems store chief complaint in an Observation with LOINC code 8661-1 (Chief complaint - Reported). Search: fhir_search Observation with patient=[id]&code=8661-1&encounter=[encounter-id].

Vital signs search returns no results for encounter window

• Widen the date range by 1 hour on each side of the encounter period.
• Try searching without date filter and take the most recent set: patient=[id]&category=vital-signs&_sort=-date&_count=10.
• Some systems store vitals under the encounter reference directly: try encounter=[encounter-id] as a search parameter on Observation.

Lab results return as referenced Observation groups rather than individual values

• If an Observation has hasMember references, follow each reference with fhir_read to retrieve individual result values.
• Panel-level Observations (e.g., CBC panel LOINC 58410-2) contain component results; check Observation.component array for individual values.

Related Skills

• history-and-physical-generator - For comprehensive H&P documentation on admission
• progress-note-writer - For daily inpatient progress notes
• clinical-summary-generator - For broader clinical summary beyond a single encounter
• problem-list-review - For validating the assessment problem list