--- name: medical-soap-note-creation description: Transform unstructured clinical encounters into comprehensive SOAP notes with ICD codes and care plans --- # Medical SOAP Note Creation This skill provides a systematic approach to converting unstructured clinical encounter summaries into professional, comprehensive SOAP notes ready for electronic health record documentation. ## Overview SOAP notes organize clinical information into four standard sections: - **S**ubjective: Patient's reported symptoms and history - **O**bjective: Measurable clinical findings and data - **A**ssessment: Clinical diagnosis and reasoning - **P**lan: Treatment strategy and follow-up ## Step-by-Step Instructions ### Step 1: Extract Key Information Review the clinical encounter summary and identify: - Patient demographics (age, sex, relevant history) - Chief complaint and history of present illness - Review of systems findings - Physical examination results - Diagnostic test results (labs, imaging) - Current medications and allergies - Past medical/surgical history ### Step 2: Structure the SOAP Note Organize information into the four SOAP sections: **Subjective (S):** - Chief complaint in patient's own words - History of present illness (onset, duration, severity, aggravating/relieving factors) - Review of systems (pertinent positives and negatives) - Relevant past medical, family, and social history **Objective (O):** - Vital signs - Physical examination findings by system - Laboratory and imaging results - Current medication list **Assessment (A):** - Primary diagnosis with ICD-10 code(s) - Differential diagnoses if applicable - Clinical reasoning connecting findings to diagnosis **Plan (P):** - Medications (new prescriptions, changes, discontinuations) - Treatments and procedures - Patient education provided - Follow-up arrangements - Return precautions ### Step 3: Write the Complete Note Compose the full SOAP note in a single `write_file` operation to ensure completeness and efficiency: ```python from write_file import write_file soap_note = """SOAP NOTE Date: [Encounter Date] Patient: [Patient Name/ID] SUBJECTIVE: [Patient's reported symptoms and history in organized paragraphs] OBJECTIVE: [Clinical findings and data in organized sections] ASSESSMENT: [Diagnosis with clinical reasoning and ICD codes] PLAN: [Specific, actionable treatment steps and follow-up] """ write_file(path="soap_note.txt", content=soap_note) ``` ### Step 4: Quality Checklist Before finalizing, verify: - [ ] All four SOAP components present and clearly labeled - [ ] ICD-10 codes included for all diagnoses - [ ] Plan contains specific, actionable items with timelines - [ ] Follow-up instructions are clear and specific - [ ] Return precautions included - [ ] Note is comprehensive (typically 3000-10000 characters for complex cases) ## Best Practices 1. **Be Specific**: Use quantifiable measurements and precise clinical terminology 2. **Include ICD Codes**: Always pair diagnoses with appropriate ICD-10 codes 3. **Actionable Plans**: Ensure each plan item has clear next steps, dosages, and timelines 4. **Single Operation**: Write the complete note in one `write_file` operation for efficiency and consistency 5. **Professional Tone**: Use clinical language appropriate for medical records 6. **Patient-Centered**: Include patient education and shared decision-making when applicable ## Example Structure ``` SOAP NOTE Date: 2024-01-15 Patient: [Name], [Age], [Sex] SUBJECTIVE: CC: [Chief complaint] HPI: [History of present illness using OLDCARTS or similar framework - onset, location, duration, characteristics, aggravating/relieving factors, timing, severity] ROS: [Review of systems - pertinent positives and negatives by system] PMH: [Past medical history] PSH: [Past surgical history] Medications: [Current medications with dosages] Allergies: [Known allergies and reactions] FH: [Family history] SH: [Social history] OBJECTIVE: VS: T [temp], BP [blood pressure], HR [heart rate], RR [respiratory rate], SpO2 [oxygen saturation], Wt [weight] General: [Appearance, distress level] HEENT: [Head, eyes, ears, nose, throat findings] CV: [Cardiovascular examination] Resp: [Respiratory examination] Abd: [Abdominal examination] MSK: [Musculoskeletal examination] Neuro: [Neurological examination] Skin: [Dermatological findings] Labs: [Relevant laboratory results with values and reference ranges] Imaging: [Imaging study results] ASSESSMENT: 1. [Primary diagnosis] - ICD-10: [code] [Brief clinical reasoning supporting diagnosis] 2. [Secondary diagnosis if applicable] - ICD-10: [code] [Brief clinical reasoning] PLAN: 1. Medications: - [Medication name] [dosage] [route] [frequency] for [duration] 2. Treatments: - [Specific treatment or procedure] 3. Patient Education: - [Education topics discussed] 4. Follow-up: - Return to clinic in [timeframe] for [purpose] - [Any scheduled tests or appointments] 5. Return Precautions: - Return immediately if [warning symptoms] ``` ## Common ICD-10 Code Categories - Respiratory: J00-J99 (e.g., J06.9 acute upper respiratory infection) - Digestive: K00-K95 (e.g., K21.0 GERD with esophagitis) - Musculoskeletal: M00-M99 (e.g., M54.5 low back pain) - Cardiovascular: I00-I99 (e.g., I10 essential hypertension) - Endocrine: E00-E89 (e.g., E11.9 type 2 diabetes mellitus) - Infectious: A00-B99 (e.g., J02.9 acute pharyngitis) ## Notes on Efficiency Writing the complete SOAP note in a single `write_file` operation offers several advantages: - Reduces iteration overhead - Ensures consistency across all sections - Prevents partial or incomplete documentation - Maintains coherent clinical reasoning throughout - Faster completion time for clinical documentation tasks --- Source attribution: zhanghong3721 Original project: https://github.com/zhanghong3721/kimiclaw/blob/a56eb2c0cba8a30e497cee4f4a4c79aa1f76aff0/openspace/gdpval_bench/skills/medical-soap-note-creation/SKILL.md License: MIT License information: https://opensource.org/license/mit Original upstream instructions; downloaded from Dave AI. ## Upstream license notice MIT License Copyright (c) 2026 ✨Data Intelligence Lab@HKU✨ Permission is hereby granted, free of charge, to any person obtaining a copy of this software and associated documentation files (the "Software"), to deal in the Software without restriction, including without limitation the rights to use, copy, modify, merge, publish, distribute, sublicense, and/or sell copies of the Software, and to permit persons to whom the Software is furnished to do so, subject to the following conditions: The above copyright notice and this permission notice shall be included in all copies or substantial portions of the Software. THE SOFTWARE IS PROVIDED "AS IS", WITHOUT WARRANTY OF ANY KIND, EXPRESS OR IMPLIED, INCLUDING BUT NOT LIMITED TO THE WARRANTIES OF MERCHANTABILITY, FITNESS FOR A PARTICULAR PURPOSE AND NONINFRINGEMENT. IN NO EVENT SHALL THE AUTHORS OR COPYRIGHT HOLDERS BE LIABLE FOR ANY CLAIM, DAMAGES OR OTHER LIABILITY, WHETHER IN AN ACTION OF CONTRACT, TORT OR OTHERWISE, ARISING FROM, OUT OF OR IN CONNECTION WITH THE SOFTWARE OR THE USE OR OTHER DEALINGS IN THE SOFTWARE. # Dave AI resource metadata Creator / publisher: zhanghong3721 Original project: https://github.com/zhanghong3721/kimiclaw/blob/a56eb2c0cba8a30e497cee4f4a4c79aa1f76aff0/openspace/gdpval_bench/skills/medical-soap-note-creation/SKILL.md Attribution basis: Source repository record Fields of work: Education & Research, Healthcare & Life Sciences Roles: Academic Writer, Clinical Research, Health Informatics, Medical Writer, Tutor / Instructor Specialties: Specialty not specified Tools: Write_File Country applicability: Country not specified Classification basis: Source catalog labels Instruction SHA-256: fde1232abf333d7b674a8c5d4411d9d3f394cf7fa1d247240eeb714c08903190