# SoapClerk — Full LLM Clinical Charting Reference (https://soapclerk.com)

## Primary Care & Outpatient SOAP (SOAP) — https://soapclerk.com/chart/soap-note-generator-ai
- Sample 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.

## Med-Surg Nursing Shift Change (SBAR) (SBAR Shift Report) — https://soapclerk.com/chart/nursing-shift-change-report-sheet
- Sample Shorthand: Rm 402B post-op day 2 lap chole, afebrile 98.4F, BP 124/78, JP drain 25mL serosanguinous, ambulated 200ft x2, pain 3/10 on PO Tylenol, awaiting AM labs.

## General Clinical SOAP Charting (SOAP) — https://soapclerk.com/chart/soap-note-examples-and-generator
- Sample Shorthand: Follow-up HTN & T2DM. Home BP avg 128/82. A1c down to 6.7%. Tolerating Metformin 1000mg BID & Lisinopril 20mg daily. No hypoglycemia or cough.

## Psychotherapy & Counseling (SOAP) (SOAP) — https://soapclerk.com/chart/mental-health-therapy-soap-note
- Sample Shorthand: 50-min individual CBT session. Client reported decreased panic episodes (1x this wk vs 4x last wk). Practiced cognitive restructuring around workplace perfectionism.

## Behavioral Health DAP Note (DAP) — https://soapclerk.com/chart/dap-note-generator-mental-health
- Sample Shorthand: Telehealth session. Affect congruent, mood euthymic. Reviewed sleep hygiene log (avg 6.5h/night). Assigned behavioral activation worksheet for weekend social exposure.

## Community Mental Health BIRP Note (BIRP) — https://soapclerk.com/chart/birp-note-generator-counseling
- Sample Shorthand: Client arrived on time, engaged actively. Therapist utilized motivational interviewing to explore ambivalence around medication adherence. Client agreed to daily pill organizer.

## Outpatient Orthopedic Physical Therapy (SOAP) — https://soapclerk.com/chart/physical-therapy-soap-note-generator
- Sample Shorthand: Status post L ACL recon wk 6. Flexion improved to 118 deg, extension 0 deg. Completed 3x12 closed-chain mini squats, step-ups, and 10 min stationary bike with minimal quad fatigue.

## Pediatric & Adult Occupational Therapy (SOAP) — https://soapclerk.com/chart/occupational-therapy-soap-note-generator
- Sample Shorthand: 30-min OT session targeting fine motor pincer grasp and bilateral coordination. Completed 4/5 buttoning trials with min verbal cues; improved tripod pencil grip endurance to 8 mins.

## Speech-Language Pathology (SLP) (SOAP) — https://soapclerk.com/chart/speech-therapy-slp-soap-note
- Sample Shorthand: Articulation therapy targeting initial/medial /r/ at sentence level. Produced target phoneme with 82% accuracy across 40 trials given minimal tactile-visual placement cues.

## Special Education & SLP IEP Goals (IEP Goal) — https://soapclerk.com/chart/iep-goal-generator-special-education
- Sample Shorthand: 4th grade student reading comprehension & multi-step word problems; currently 45% accuracy on main idea identification; target 80% accuracy across 4 consecutive probes.

## Chiropractic Adjustment & Exam SOAP (SOAP) — https://soapclerk.com/chart/chiropractic-soap-note-generator
- Sample Shorthand: Cervical & lumbar segmental dysfunction C5-C6, L4-L5. Decreased R lateral flexion. Performed diversified HVLA adjustment to C5, T4, L4 with audible release and immediate ROM gain.

## Licensed Massage Therapy (LMT) SOAP (SOAP) — https://soapclerk.com/chart/massage-therapy-soap-note-generator
- Sample Shorthand: 60-min myofascial & deep tissue session focusing on upper trapezius and levator scapulae hypertonicity. Trigger point release reduced reported tension from 7/10 to 2/10.

## ICU Critical Care Nursing SBAR (SBAR Shift Report) — https://soapclerk.com/chart/icu-nursing-shift-report-sheet
- Sample Shorthand: 64yo M septic shock on Levophed 0.06 mcg/kg/min, MAP > 68, weaned FiO2 to 40%, UOP 55mL/hr clear yellow, lactates trending down 3.1 -> 1.6, family updated at bedside.

## Emergency Department Triage & MDM (SOAP) — https://soapclerk.com/chart/emergency-room-triage-soap-note
- Sample Shorthand: 29yo M acute RLQ abdominal pain x8h, nausea, temp 100.6F, Rovsing positive, WBC 14.2, CT abdomen ordered to r/o acute appendicitis, IV NS bolus + Zofran given.

## EMS / Paramedic ePCR SOAP Narrative (SOAP) — https://soapclerk.com/chart/ems-paramedic-soap-narrative-generator
- Sample Shorthand: Dispatched Priority 1 for 58yo F chest pressure. Found sitting tripod A&Ox4, GCS 15, SpO2 94% RA -> 99% on 2L NC, 12-lead NSR without STEMI, ASA 324mg PO chewed, transported code 2.

## Psychiatry & PMHNP Med Management (SOAP) — https://soapclerk.com/chart/psychiatric-medication-management-soap
- Sample Shorthand: MDD & GAD 4-wk follow-up on Escitalopram 10mg daily. PHQ-9 dropped from 16 to 9, GAD-7 from 14 to 7. Denies SI/HI, no activation or GI side effects. Continue current dose.

## Pediatrics Well-Child & Sick Visit (SOAP) — https://soapclerk.com/chart/pediatric-well-child-soap-note
- Sample Shorthand: 4yo M with 2 days bilateral ear tugging and low-grade fever 101.1F. R TM erythematous and bulging with decreased mobility; L TM clear. Lungs CTAB. Start Amoxicillin 90mg/kg/day.

## Dental & Periodontal Chart Note (SOAP) — https://soapclerk.com/chart/dental-hygiene-clinical-soap-note
- Sample Shorthand: Adult prophylaxis & BWX x4. Generalized mild gingivitis, localized 4mm pockets #3, #14 with BOP. Ultrasonic scaling + hand instrumentation completed, fluoride varnish applied.

## Optometry & Ophthalmology SOAP (SOAP) — https://soapclerk.com/chart/optometry-eye-exam-soap-note
- Sample Shorthand: Annual comprehensive eye exam. BCVA 20/20 OU with -2.25 DS OD, -2.50 DS OS. IOP 14/15 mmHg Goldmann. Anterior segment clear, C/D ratio 0.3 OU healthy macula.

## Veterinary Medicine (DVM) SOAP (SOAP) — https://soapclerk.com/chart/veterinary-soap-note-generator
- Sample Shorthand: 5yo castrated male Golden Retriever, 32kg, acute pruritic otitis externa AU. Cytology shows 3+ Malassezia yeast, no rods. Cleaned ears in clinic, dispensed Posatex otic SID x7d.

## Dermatology Lesion & Biopsy SOAP (SOAP) — https://soapclerk.com/chart/dermatology-skin-biopsy-soap-note
- Sample Shorthand: Full body skin exam + 4mm punch biopsy of changing 6mm asymmetric pigmented macule on L superior scapular back. Informed consent obtained, 1% lidocaine w/ epi, 4-0 nylon suture x1.

## Wound Care & Home Health Nursing (SOAP) — https://soapclerk.com/chart/wound-care-nursing-soap-note
- Sample Shorthand: Stage 2 sacral pressure injury 2.1cm x 1.8cm x 0.2cm, 100% pink granulation tissue, scant serous exudate, no periwound maceration or odor. Cleansed w/ NS, applied hydrocolloid dressing.

## ABA Therapy (RBT / BCBA) Session Note (SOAP) — https://soapclerk.com/chart/aba-therapy-session-note-generator
- Sample Shorthand: 2-hour home ABA session. Manding for preferred items reached 88%獨立 across 25 opportunities. Implemented token economy and DRA during transitions; zero elopement episodes.

## Registered Dietitian (RDN) ADIME/SOAP (SOAP) — https://soapclerk.com/chart/dietitian-nutrition-adime-soap-note
- Sample Shorthand: MNT for newly diagnosed prediabetes (A1c 6.1%, BMI 29.4). Reviewed 24-hr recall; high evening refined carb intake. Established SMART goal: 25g fiber/day + 20-min post-dinner walk.

## Acupuncture & TCM Clinical SOAP (SOAP) — https://soapclerk.com/chart/acupuncture-tcm-soap-note-generator
- Sample Shorthand: Chronic migraine & Liver Qi stagnation pattern. Pulse wiry, tongue slightly red sides with thin white coat. Needled LI4, LV3, GB20, Yintang bilateral for 25 mins with deqi.

## Licensed Clinical Social Work (LCSW) (SOAP) — https://soapclerk.com/chart/social-work-case-management-soap-note
- Sample Shorthand: Home visit & housing stability check-in. Assisted client in completing LIHEAP utility assistance renewal and coordinated transportation voucher for Friday oncology follow-up.

## IOP / Group Therapy Progress Note (SOAP) — https://soapclerk.com/chart/substance-abuse-group-therapy-soap-note
- Sample Shorthand: 90-min relapse prevention group (8 members). Topic: identifying HALT triggers. Client shared personal coping strategy with peers and demonstrated strong insight into high-risk social cues.

## Athletic Training (ATC) Ortho Evaluation (SOAP) — https://soapclerk.com/chart/athletic-training-injury-soap-note
- Sample Shorthand: Varsity soccer player Grade 1 R lateral ankle inversion sprain. Ottawa ankle rules negative for fracture. Mild ATFL tenderness, +1 anterior drawer. Rest, ice, compression wrap, proprioception rehab.

## Virtual Urgent Care Telemedicine SOAP (SOAP) — https://soapclerk.com/chart/telehealth-urgent-care-soap-note
- Sample Shorthand: Video visit for 3d acute sinus congestion, facial pressure, purulent rhinorrhea, no high fever or vision changes. Advised saline irrigation, Flonase nasal spray, and supportive care.

## Hospital Inpatient Discharge Summary (SOAP) — https://soapclerk.com/chart/discharge-summary-clinical-generator
- Sample Shorthand: 3-day admission for community-acquired pneumonia. Responded well to IV Ceftriaxone/Azithromycin; transitioned to PO Doxycycline to complete 5-day course. Room air SpO2 97% at discharge.