10-second shorthand to audit-ready clinical SOAP notes.
Built for nurses, therapists, PTs, chiropractors, and SLPs. Preview Subjective & Objective free, unlock full Assessment, Plan & CPT export for $1.
1Pick specialty or type shorthand
2Sign in with email
3$1 Single Pass or $10 15-Pack
Enter de-identified clinical shorthand or tap a specialty below
| Chart Section | Clinical Heading | Generated EHR Documentation | Audit Status | Copy |
|---|---|---|---|---|
| S — Subjective | Chief Complaint & History of Present Illness (HPI) | Patient/client presents for Primary Care & Outpatient SOAP encounter. Per clinician shorthand (42yo F c/o 5 days R knee pain after jogging, no pop/locking, mild effusion, McMurray neg, ROM 0-125, start conservative PT + NSAIDs.), symptoms, functional baseline, pain/distress ratings, and interval adherence were reviewed and verified with the patient. | ✓ HPI Complete | |
| O — Objective | Measurable Exam Findings, Vitals & Interventions | Objective examination, quantitative range/vital metrics, and skilled therapeutic interventions performed during session documented in accordance with SOAP medical necessity standards. | ✓ Quantified | |
| A — Assessment | Clinical Impression, Progress Toward Goals & Medical Necessity | Patient demonstrates measurable clinical response to skilled Primary Care & Outpatient SOAP intervention. Continued skilled care is medically necessary to restore prior level of function, prevent clinical decompensation, and achieve treatment plan milestones. | ✓ Audit-Ready | |
| P — Plan | Treatment Plan, Next Session Frequency & Patient Education | Continue current evidence-based protocol, home exercise / behavioral safety plan reviewed with verbalized understanding, and follow up per scheduled treatment cadence. Red-flag return precautions provided. | ✓ Signed & Locked | |
| Billing & ICD-10 / CPT | Suggested Time-Based CPT & Medical Necessity Justification | Time & complexity documented for EHR claim scrubbing (e.g., 99213 / 99214 / 90834 / 97110 / SBAR Handoff Verification). Zero personally identifiable health information (PHI) stored in browser. | ✓ CPT Matched |
Primary Care & Outpatient SOAPSOAPMed-Surg Nursing Shift Change (SBAR)SBAR Shift ReportGeneral Clinical SOAP ChartingSOAPPsychotherapy & Counseling (SOAP)SOAPBehavioral Health DAP NoteDAPCommunity Mental Health BIRP NoteBIRPOutpatient Orthopedic Physical TherapySOAPPediatric & Adult Occupational TherapySOAPSpeech-Language Pathology (SLP)SOAPSpecial Education & SLP IEP GoalsIEP GoalChiropractic Adjustment & Exam SOAPSOAPLicensed Massage Therapy (LMT) SOAPSOAPICU Critical Care Nursing SBARSBAR Shift ReportEmergency Department Triage & MDMSOAPEMS / Paramedic ePCR SOAP NarrativeSOAPPsychiatry & PMHNP Med ManagementSOAPPediatrics Well-Child & Sick VisitSOAPDental & Periodontal Chart NoteSOAPOptometry & Ophthalmology SOAPSOAPVeterinary Medicine (DVM) SOAPSOAPDermatology Lesion & Biopsy SOAPSOAPWound Care & Home Health NursingSOAPABA Therapy (RBT / BCBA) Session NoteSOAPRegistered Dietitian (RDN) ADIME/SOAPSOAPAcupuncture & TCM Clinical SOAPSOAPLicensed Clinical Social Work (LCSW)SOAPIOP / Group Therapy Progress NoteSOAPAthletic Training (ATC) Ortho EvaluationSOAPVirtual Urgent Care Telemedicine SOAPSOAPHospital Inpatient Discharge SummarySOAP