Complete SOAP notes from dictated shorthand
Documentation is where physician AI has delivered its clearest win: Permanente's ambient scribes saved nearly 16,000 hours across 2.5 million encounters, with 84% of physicians reporting better patient communication. If your organization has an ambient scribe, use it — this prompt covers the same job for physicians without one, turning post-visit shorthand into a complete, signable note instead of an evening of pajama-time charting.
You are a medical scribe converting my dictated shorthand into a complete clinical note. Visit type: {{visit_type}}. My shorthand (de-identified): {{shorthand}} Produce a SOAP note: - S: chief complaint in the patient's words if I gave them, relevant history, pertinent positives and negatives I mentioned. - O: vitals, exam findings, and results exactly as dictated — never normalize or expand an exam I did not describe. - A: assessment as dictated, with differential only if I dictated one. - P: plan as dictated — orders, prescriptions, referrals, counseling, follow-up interval, and return precautions. Rules: - Use only what is in my shorthand. Where a standard element for this visit type is missing (review of systems, time spent, counseling documentation), write [VERIFY: element] — do not fill it with boilerplate. A templated normal exam I did not perform is a false record. - Past tense, factual, no editorializing about the patient. - Expand ambiguous abbreviations; keep standard ones. - After the note, list what a coder would still need to support the E/M level this visit type usually bills, based only on what is present or missing above.
Fill in your details and the prompt updates live — then copy.
S: Established patient presented for hypertension follow-up. Reported home blood pressures in the 130s/80s. Tolerating lisinopril without cough. [VERIFY: medication adherence discussion] O: BP 132/84, HR 72. Lungs clear to auscultation. No peripheral edema. A: Hypertension, improved control on current therapy. Hyperlipidemia, surveillance due. P: Continue lisinopril 20 mg daily. Fasting lipid panel ordered. Return to clinic in 6 months, sooner for home BP consistently above 140/90. [VERIFY: total time or counseling time if billing on time] Coder needs: documented ROS elements and time statement to support 99213 vs 99214.
The full workflow
- Dictate or type shorthand immediately after the visit, while details are fresh
- Run the prompt and resolve every [VERIFY] flag against what actually happened
- Delete anything the note claims that you did not do — then sign
- Paste into the EHR, and push your group to evaluate a BAA-covered ambient scribe for the full workflow
Watch out for
The signed note is the legal record. Models insert plausible boilerplate — an exam you did not perform or counseling you did not give is a false record and a billing-fraud exposure.
HIPAA: shorthand with a name, MRN, or exact date is PHI. Keep identifiers out of consumer tools; ambient scribes used at health systems run under BAAs for a reason.
Do not let the note upcode itself — the E/M level must match what is documented and what actually occurred.
Where this comes from
Every use case on this site is grounded in real reports from working physicians — not invented by us.