AI SOAP Notes: The Ultimate Guide for Faster Clinical Documentation

Introduction to AI SOAP Notes

Taking notes is a crucial aspect of offering patient consultation and treatment, but manual note-taking is not only time-consuming but it can also make your patients feel less heard, leading to a poor patient experience. To address this, many healthcare professionals are embracing AI SOAP note-takers and we think you should too. 

So what are AI SOAP notes? What are its benefits, and what problem can it solve? Keep reading to find out the answers to these and any other questions you may have. 

What are AI SOAP Notes?

SOAP notes are a standardized method of gathering patient and clinical data so that the clinician can assess, track, and diagnose the patient by referring to the SOAP notes they made. SOAP is an acronym that stands for:

1. Subjective (S): This section contains the symptoms experienced by the patients, their health history or any other concern they may face. 
2. Objective (O): This section contains the objective data such as Patient’s vitals, lab results, exam findings, blood test results, or any other measurable data.
3. Assessment (A): Here the clinician connects the subjective and objective data to assess the cause of the concern that patient came up with. Here’s where the doctor applies their clinical judgement to determine what is the actual issue. 
4. Plan (P): This section contains the proposed treatment or plan of action, including diagnostic tests, next steps, treatment strategy, etc.

This was done by humans earlier, but now, healthcare providers are embracing AI for taking SOAP notes. AI does this by transcribing a call or by listening to a live conversation, allowing the clinician to focus on patient care instead of taking notes manually. 

How Do SOAP Notes AI Work?

So how do AI SOAP notes work? Right from capturing patient encounters to feeding the SOAP notes into the EHR, SOAP notes AI makes the whole process seamless. 

AI Captures patient encounter

So the SOAP note AI tool starts by capturing the patient encounter during or immediately after the visit. This could include transcribing during a live session, listening to a call or telehealth session. For this, the AI uses speech recognition and ambient intelligence.

AI transcribes the encounter & collects data

Now the AI starts transcribing the call, video, or live interaction and starts documenting relevant clinical information. While transcribing the interaction, it identifies and categorizes the notes into SOAP note components. 

Generates SOAP notes

Based on the data collected by the AI, it starts generating the SOAP notes. The format could vary depending on the template chosen by the healthcare provider specific to their practice or specialty. 

Clinicians review & edit the SOAP notes

Once the SOAP notes are generated, the clinician reviews it and makes small changes as needed. To ensure proper HIPAA compliance, it is best that the clinician always reviews the SOAP note generated by the AI. 

Integration with EHR/EMR

The finalized SOAP notes are then integrated into the EHR system used by the healthcare provider. This quick integration makes it possible to update patient information quickly by avoiding redundancy and repetition.

Challenges in Traditional SOAP Note-Taking

Let us understand the challenges in traditional SOAP note taking before we dive deep into the benefits and use cases of SOAP note AI. 

Time consuming

Taking SOAP notes traditionally can take anywhere from 5-10 minutes per patient. It is not only time consuming but also inconvenient when trying to focus on patient interaction completely without any distractions. Moreover, keeping track of paper notes or simply finding them in a pile of other notes further adds to time wastage. 

SOAP note documentation errors

Manual note taking is prone to errors with studies showing 20% of malpractice cases involve documentation errors. Handwritten notes can often be illegible and misreading or misinterpreting these notes can lead to incorrect treatments or diagnoses, and increase the likelihood of costly legal disputes. 

Redundancy & repetition

If you are treating an old patient, then you might already have their information available in your EHR system. But in traditional note-taking, you are often forced to re-enter patient information (vitals, history, etc.,) which leads to repetition and redundancy. Moreover, many clinicians copy old notes, which may be outdated and lead to wrong SOAP note documentation. 

Cognitive load & burnout

Administrative load is one of the biggest reasons for physician burnout, and healthcare providers often feel more like data entry clerks than caregivers. Traditional note-taking can increase the cognitive load and burnout in healthcare providers, resulting in poor patient care and outcomes.

Inconsistency

Sometimes a patient may be asked to go to different doctors in a hospital to identify the cause of their problem. In this case, notes can vary widely between different providers. Important things might be missed or details might be recorded in inconsistent format making it difficult for the next provider to understand the notes clearly. 

Impact on patient care

Excessive SOAP note documentation can distract the healthcare provider from focusing completely on patient interaction. When the provider breaks eye contact to take manual notes, it can make patients feel unheard or less important, leading to poor patient satisfaction.  

What Problems Does AI SOAP Notes Solve?

1. Pre-visit or SMS intake

The current scenario looks like this: A patient reaches out to a clinic via call or SMS, describes their issue in brief, and asks for an appointment. On the day of their appointment, the staff shares the same with the doctor- this can be prone to errors and is also time-consuming. The patient describes their issues to the doctor again; not only does this ruin the patient’s experience, but makes the doctor feel burned out from the constant note-taking. AI can simplify all this by capturing symptoms right from the first call/SMS, making the patient’s concerns clear before the visit even starts. It saves clinicians time by doing the “pre-work” of sifting through unstructured data and highlighting what matters most.

2. Voice-to-Text (VoIP)

Clinicians can’t always take detailed notes on call. Important details on a call can be misremembered or forgotten. AI can listen to the initial phone call with the patient, identify their complaint (e.g., – jaw clenching, tooth pain, etc.), and auto summarize it for the subjective section of the SOAP note. 

3. Automated Data Integration

Manually checking patient history or pulling EHR data can be quite tedious. AI can be integrated with your EHR system and can pull patient histories such as past dental history, latest vitals, radiographic images, and summaries and create the Objective section of the SOAP note. This allows the clinician to access relevant diagnostics and make faster clinical decisions. 

4. Efficiently Drafting the SOAP Note

Writing SOAP notes manually is time-consuming and error-prone. After gathering relevant information from the SMSs/Calls, EHR system, etc., AI drafts a full SOAP note — from Subjective and Objective to Assessment and Plan, helping clinicians focus on patient care and interaction rather than note taking. 

5. Reducing Dirty Claim Rates

AI SOAP note takers help reduce insurance claim rejections by automatically creating accurate and complete notes that include the right billing codes. They check patient insurance details and spot mistakes before claims are sent, making sure all required information is included. This reduces errors that cause claims to be denied, helping doctors get paid faster and with fewer problems.

Benefits of AI SOAP Notes

Let us look at how AI can help deal with all the challenges associated with traditional note-taking both for healthcare professionals:

• Saves time: AI SOAP notes generator reduces 50-70% of time that goes into traditional note taking and helps in saving a lot of time.
• Standardizing documentation: The style of taking SOAP notes might vary from practitioner to practitioner. However, AI offers consistent templates for different healthcare specialties and helps in standardizing note-taking and minimizing errors related to format or completeness. 
• Minimizing Redundancy: By integration with EHR tools, AI eliminates the need to enter repetitive manual patient info into the system and reduces redundancy. 
• Reducing cognitive load & burnout: By listening and scribing a live conversation, AI eliminates the need for the practitioner to look at their screens again and again, and helps to reduce cognitive and load burnout. 
• Allow providers to focus on patient care: Since AI takes away the task of note-taking, it helps clinicians be present and focus on patient care entirely.
• Reducing errors to maintain consistency: AI helps minimize the mistakes made during manual typing or writing to maintain consistency and in avoiding serious consequences. 
• Ensures readability for all healthcare teams: Human notes can often be illegible, making it hard for the healthcare team to interpret things correctly. However, notes documented by AI ensure proper readability for the entire team. 

Use Cases of AI SOAP Notes in Different Healthcare Industries

• Primary Care and General Medicine: Primary or general medicine clinics often see high-volume patients. AI pulls the symptoms shared by the patient via voice or text, pulls their vitals from EHR, and generates a draft SOAP note in real time. This helps them save 2-3 hours/day & help improve follow-up frequency.
• Dental Practices: AI SOAP note generator gathers dental symptoms via SMS intake or call and drafts a SOAP note specific to dental terminology. It helps the dentist save time in drafting notes and also helps in coming up with post-care instruction and care plans without spending too much time.  
• Behavioral Health / Therapy: Therapists can use therapy notes AI to focus on patients more while automating mental health note taking during live sessions, be it for individuals, couples, etc. 
• Telemedicine / Virtual Care: AI SOAP notes tool helps in note-taking during a remote consultation or care by analyzing voice or video calls and generating the relevant course of action for the treatment. 
• Urgent Care / Walk-In Clinics: Urgent care or walk-in clinics usually see short visits or visitors with acute conditions. AI captures real-time voice-to-text and helps in providing faster resolution to ensure high turnover. 

How do AI SOAP Note Tools Ensure HIPAA Compliance in Real-Time During Note Generation?

To maintain HIPAA compliance, AI SOAP note generators implement several security features, including:

• End-to-end encryption: AI SOAP notes software implements TLS 1.2+ or AES-256 type encryption to prevent eavesdropping or interception of sensitive PHI. 
• User/Role-based access: AI SOAP notes tools implement role-based access or two-factor authentication features to limit access to the documented notes.
• Audit trails: To help detect unauthorized access, AI SOAP tools log every edit and access details and create audit trails. 
• HIPAA-Compliant cloud infrastructure: Many SOAP notes AI tools run on HIPAA compliant environments like AWS HealthLake, Microsoft Azure, etc.
• BAA: Legit AI SOAP notes software sign BAA agreements with healthcare providers to ensure they legally comply with HIPAA standards. 

Look for HIPAA compliant ai note taking features when looking for an AI tool to ensure necessary compliance always. 

Can Tools Like ChatGPT be Used for Soap Notes?

Many healthcare providers use ChatGPT for taking SOAP notes as it is easily accessible and also free to use. However, AI tools like ChatGPT are built on Large Language Models (LLM models), which are trained on a vast amount of public data. Since LLM AI tools like ChatGPT are not built to handle medical specializations, they can assume things and generate biased or incorrect responses. To avoid any such errors, medical professionals should invest in AI built specifically for SOAP notes. Additionally, they should consider integrating their SOAP note taker with patient engagement and communication software like Emitrr to enhance its effectiveness and efficiency.

How AI SOAP Notes Handle Complex Medical Terminology & Abbreviations?

Many healthcare practitioners scare away from using AI SOAP notes software thinking how it will handle complex medical terminology and abbreviations. But if you use AI tools built specifically for healthcare practitioners, then you don’t have to worry about this. Here’s how AI SOAP notes handle complex medical terms & context:

• Contextual Understanding: Thanks to NLP Advances, AI tools can now consider sentence context. For e.g., “MI” in cardiology likely means myocardial infarction, but in a psychiatry note, it could mean motivational interviewing.
• Medical Dictionaries Integration: Many SOAP note tools integrate with medical dictionaries which helps them in understanding medical jargon, and shorthand into full context-aware descriptions. (For e.g., they can understand “ASA” stands for “Aspirin”) 
• Pre-trained Medical Language Models: Medical specific AI systems are often built on models trained with clinical datasets, medical journals, and EHR records, which helps them in medical note taking and documentation. 

Why Emitrr is the Best AI SOAP Notes Software?

Emitrr is a popular patient engagement tool offering features like SOAP notes, SMS, VoIP, AI, appointment reminders & scheduling and reputation and review management. Emitrr is known for its affordable pricing plans and it is rated 5/5 for its unparalleled customer support by users on Capterra. Here’s why Emitrr is the best AI SOAP notes tool: 

Built for Healthcare Workflows

Emitrr isn’t your basic automation tool, it’s an all-in-one CRM for healthcare. From automating repetitive tasks to streamlining patient interaction, everything is designed to lighten the load on your staff so they can focus on what really matters.

Seamless Integrations with your systems

No more juggling between platforms. Emitrr works hand-in-hand with popular EHRs and EMRs, ensuring accurate real-time syncing of data. This means fewer errors, smoother claims, and better coordination across your team.

Keeps You HIPAA-Compliant

Worried about data privacy? Emitrr has got your back. It follows strict HIPAA guidelines to ensure patient feedback stays secure, so you can automate with confidence and peace of mind.

Easy to Use and Scale

You don’t need to be tech-savvy to get started with Emitrr. Its intuitive interface makes it easy for teams to adapt quickly. And as your practice grows, Emitrr grows with you, no disruptions, no headaches.

Unparalleled Customer Service

Emitrr offers quick and useful resolution 24/7 and is known for its unparalleled customer service. In fact, users have rated Emitrr a solid 5/5 for its customer service on popular software review platform- Capterra. 

Here’s How You Can Use Emitrr For Taking SOAP Notes and More!

Let us have a look at how you can use Emitrr’s AI SOAP note and other tools during the complete patient journey:   

1. Patient Communication & Intake 

You can use Emitrr to automate pre-visit SMS, digital intake forms, or reminders for things like symptom checklists, consent forms, etc. From the responses to these SMS, Emitrr’s AI can extract clinical data such as (bleeding gums, tooth sensitivity, etc.) and populate them into the subjective section of SOAP notes. 

Benefit: The doctor or staff does not need to switch between inboxes or EHR messages. Emitrr will document relevant things right from the first patient interaction. 

2. Two-Way Texting/Calls & AI Voice Transcription & Summarization

Emitrr supports two way texting as well as VoIP phone, all of which can be recorded and logged with HIPAA compliant AI. Emitrr’s SOAP AI tool can then transcribe and summarize the call or two-way conversation.

Benefit: The doctor does not need to make notes while on call, the AI does the job for them by accessing the recorded VoIP calls/SMS offered by Emitrr.

3. Appointment Scheduling & Pre-Charting 

You can send confirmation and automated scheduling links to patients using Emitrr. This software not only takes care of the appointment scheduling, but also pre-charts the visit by using data that it gathered before.

Benefit: By the time your patient actually visits you, most of the pre-charting is already done and the doctor can focus on patient care more than the paperwork. This also helps in quick assessment and helps in reducing patient wait time.

4.  Post-Visit Follow-Ups & Instructions 

You can schedule/send post-visit follow-up SMS or instructions to your patients easily using Emitrr. And then the AI can log the plan (e.g., “start on antibiotics,” “return in 2 weeks”) into the SOAP note, which can then be delivered directly to the patient.

Benefit: The staff can use Emitrr’s customized templates for this and not only save time but also offer a better patient experience. 

By using this powerful software, Doctors can reduce so much administrative tasks, paperwork and engage with their patients better. Book a free demo with Emitrr now, and see for yourself what a game changer it can be for your medical practice. 

Future of AI SOAP Notes

The future of AI SOAP Notes (Subjective, Objective, Assessment, Plan) is set to evolve in many ways, making note-taking more seamless. AI tools are being built to evolve into true ambient scribes to be able to understand human emotions, detect tone, urgency, etc. They will learn documentation styles for specific healthcare specializations and will be able to transcribe notes in multiple languages. There would be more autonomy and transparency added to them so that clinicians can understand why AI interpreted or recommended something. Apart from this, AI SOAP note tools will also offer better and more seamless integration with the EHR system and may help predict illnesses that the provider may miss at that moment.  

Frequently Asked Questions

Conclusion

The AI SOAP note tool is helping many healthcare providers cut down time on paperwork and use the same on more pressing matters such as patient health. However, to get the best out of your AI SOAP software, we recommend you to club it with your existing patient communication system.

If you don’t have a patient communication software then we strongly recommend you to book a free demo with Emitrr which is a patient communication software offering features like SMS, VoIP, email, AI, healthcare reviews & reputation management, and patient appointment & scheduling. 

The best part is that Emitrr is currently building AI SOAP note functionality as well, so you can simply invest in one tool and get access to all these features without the hassle of learning multiple tools.