Dr. K SOAP

HISTORY OF PRESENT ILLNESS

[Provide a detailed narrative of the patient's current illness or condition. Include information about symptom control, medication changes with specific doses, associated symptoms, and any other pertinent clinical details. Exclude medical history, surgical history, social history, family history, medications, allergies, and screening unless it is directly related to the history of present illness. Exclude treatment plan, any previous testing not directly related to the history of present illness, and any interpretation of lab results. Abbreviate units for measurements as follows: milligrams (mg), micrograms (mcg), and millimoles per liter (mmol/L).]

Current Medications

[List each medication the patient is currently taking in a bullet-point format. Include the name of the medication (ensure only the first letter is capitalized), dosage and frequency for each item without placing a comma between the dosage and frequency.] [Remove statement of allergies.]

PHYSICAL EXAM

[If any vitals exist with a recorded date matching visit date, display "Vital Signs:" on a new line with the following included only if date matches: Height, Weight, BP, Pulse, Temperature.] [Document each assessed system such as general and any other relevant systems examined. Use a new line for each system. Exclude reported symptoms. Exclude systems that are not assessed.] For example: Vital Signs: Blood Pressure: 120/80, Pulse 75 General: Well appearing, alert and oriented Lungs: Clear to auscultation, normal respiratory effort

Investigations

[Group all investigations performed within 3 months prior to the visit date by the date they were conducted. For each date, list the tests as bullet points. Include: test name and results if available. Do not include: Immunizations and Tests older than 90 days before the visit. If there are no investigations, this section should be omitted.] When there are multiple investigations, each with an associated date, organize the information by grouping all investigations under their respective dates. Present the content in plain text, without using markdown, bold, or any special formatting. For example: 2025-03-13: - Complete Blood Count: xxx - Creatinine: 61 umol/L 2025-02-09: - Potassium: 3.8 mmol/L

ASSESSMENT/PLAN

[For each diagnosis explicitly discussed, list the diagnosis followed by the code in parentheses. Do not include, infer, or assume any diagnoses, plans, or follow-up information that are not clearly and directly discussed. If diabetes is present, list it first and end its plan with “See diabetes flow sheet for details.” If health maintenance is present, list it first and use code 917. Provide a concise assessment and plan only for each diagnosis that is explicitly discussed. Place each diagnosis and its plan on a new line. Include follow-up appointment details only if specific timing is clearly discussed.] For example: Diabetes (250) - See diabetes flow sheet Hypertension (401) - Blood pressure is well controlled. Follow up: 3 months

Billing

Billing: [Code 1], [Code 2], [Code n]

AI Scribe Note

This note was prepared using Empathia AI. Written consent from the patient to use AI scribe.