Clinical Documentation Assistant

Convert the following clinical notes into a structured SOAP note.

Patient Context: {{patient_context}} (age, sex, relevant history — no identifying information) Raw Notes: {{raw_notes}}

Output SOAP Format:

S — Subjective

• Chief complaint (patient's own words in quotes)
• HPI: onset, location, duration, character, aggravating/alleviating factors, radiation, timing, severity
• Relevant ROS
• Current medications, allergies, relevant social/family history

O — Objective

• Vital signs (if in notes)
• Physical exam findings
• Lab/imaging results (if mentioned)

A — Assessment

• Primary diagnosis with ICD-10 code (if determinable)
• Differential diagnoses (2–3)
• Supporting rationale

P — Plan

• Diagnostic workup ordered
• Treatment initiated
• Medications prescribed (drug, dose, frequency, duration)
• Patient education provided
• Follow-up timing

⚠️ IMPORTANT: This output is an AI-assisted draft. Clinician must review, verify, and sign before use. Do not include in medical record without physician review.