How To Write SOAP Notes With Lyrebird

SOAP remains one of the most widely used clinical note structures in Australian practice, particularly in general practice and several specialist contexts. This article covers what a well-structured SOAP note contains, what Australian professional guidance expects of clinical records, where Lyrebird generates SOAP-structured drafts from consult audio, and the adjustments worth making to produce SOAP notes that match a clinician's own style.

The SOAP Structure and Its Origins

SOAP is an acronym for Subjective, Objective, Assessment, and Plan. The structure was developed by Dr Lawrence Weed in the late 1960s as part of the problem-oriented medical record. Weed's framework was designed to make clinical reasoning explicit in the chart, so that any practitioner subsequently reading the record could follow the thinking behind the clinical decisions. Nearly six decades later, the structure remains in wide use because that core purpose still matters: notes are read by other clinicians, and the reasoning embedded in them directly affects continuity of care.

The current convention in Australian general practice is broadly as follows.

Subjective captures the patient's reported symptoms, history of presenting complaint, relevant past history, medications, allergies, social and family history as relevant, and the patient's own description of their concerns. The emphasis is on what the patient reports rather than what the clinician observes.

Objective captures the clinician's observations. Vital signs, examination findings, and the results of any investigations available at the time of the consult all go here. This is what is observed or measured, distinct from what is reported.

Assessment captures the clinician's clinical reasoning. The differential diagnosis or working diagnosis, the severity or stage where relevant, and any risk stratification belong in this section. This is the cognitive work of the consult.

Plan captures what is being done. Investigations ordered, medications prescribed or adjusted, referrals made, patient education provided, follow-up arranged, and safety-netting advice all go here. This is the action output of the consult.

What Australian Guidance Expects of Clinical Notes

SOAP is a structure. The content expectations that apply to clinical notes sit above that structural choice, and are set by professional and regulatory bodies.

The RACGP Standards for general practices (5th edition), Criterion C7.1, sets out what content patient health records must contain in accredited Australian general practice. The focus is on records that are complete enough to support continuity of care, clearly identify patient and author, and contain the clinical reasoning that underpins decisions made.

The AHPRA shared Code of conduct for registered health practitioners and AHPRA's specific guidance on managing health records set the regulatory expectation. Practitioners must keep accurate, up-to-date records that can be understood by other health practitioners, hold them securely, make records at the time of events or as soon as possible afterwards, and document informed consent for treatment.

The Medical Board of Australia's Good medical practice, which came into effect in October 2020, is the profession-specific reference for doctors and covers records as part of overall professional conduct.

A well-structured SOAP note generally satisfies these expectations when completed with care, but the structural format is secondary to the substantive content.

How Lyrebird Generates SOAP Notes

Lyrebird captures the consult audio, transcribes it, and organises the clinical content into SOAP structure by default if SOAP is the clinician's selected template. The model filters out non-clinical content such as rapport-building conversation, and allocates what remains to the appropriate SOAP section based on context. Patient-reported content goes to Subjective, clinician observations and examination findings to Objective, reasoning expressed by the clinician to Assessment, and actions and plans to Plan.

The draft is available shortly after the consult ends, and writes back to Bp Premier through the Best Practice integration for Bp Premier users. Structured clinical observations such as blood pressure, temperature, and weight are placed into the correct Bp Premier observation fields rather than embedded in the note text.

Note quality is not sacrificed for speed. The Gold Coast Hospital and Health Service evaluation across 21 specialties found Lyrebird-generated notes outperformed traditional notes on the Physician Documentation Quality Instrument-9 (PDQI-9), a validated 9-item rating scale widely used in clinical evaluation research to assess attributes such as accuracy, completeness, thoroughness, and usefulness. That is specific evidence that structured AI-generated notes can meet the content-quality expectations set by Australian guidance.

Getting the Assessment Section Right

The Assessment section is the one most sensitive to how the clinician conducts the consult. The scribe can only allocate content to Assessment if reasoning is articulated in the consult. Clinicians accustomed to formulating the assessment silently and typing it afterwards see sparser Assessment sections in their drafts.

The practical adjustment is to speak the assessment aloud during the consult. Articulating the differential, the working diagnosis, and the reasoning behind either gives the scribe the content it needs to populate Assessment. This is one of the most commonly cited adjustments among clinicians transitioning to ambient documentation. It is also consistent with the broader principle that clinical reasoning visible in the chart is the reasoning that can be defended, as reflected in Australian professional guidance on record content.

Template Customisation for SOAP

Most clinicians' SOAP notes have a distinct style. Particular phrasings, preferred ordering within sections, and structural conventions develop over years of practice. Lyrebird's template customisation lets the clinician upload a handful of existing SOAP notes so the model learns these patterns.

The GCHHS lesson on optimising for reviewability identifies template adaptation as one of the factors separating clinicians reaching significant time savings from those whose gains plateaued. Investing a small amount of time in template setup in the first week typically produces drafts that read closer to the clinician's own style within the first fortnight.

Alternatives to SOAP

SOAP is not the only clinical note structure. Issues-based notes are the most common alternative in Australian general practice, particularly for complex multi-problem consults, where the note is organised by clinical problem rather than by SOAP section. Specialist letters have their own conventional structures that vary by specialty.

Lyrebird supports all of these as template options. Clinicians typically settle into two or three templates that cover most of their consults.

Review and Sign-Off

The draft SOAP note is reviewed for clinical accuracy, with particular attention to the Assessment and Plan sections, before sign-off. The clinician is the author of the record, with medicolegal responsibility unchanged. This mirrors AHPRA's expectation that the treating practitioner is responsible for the accuracy and completeness of the record.

For Bp Premier users, the finalised note writes back into the patient record with a single click, with structured observations placed into the correct Bp Premier fields. For other EMRs, the note is typically copy-and-pasted.

Reviewing for clinical accuracy rather than proofreading the full text word-for-word preserves the intended efficiency gain. The GCHHS evaluation identified review habits as one of the factors differentiating clinicians who sustained the published time savings from those whose gains plateaued.

Privacy and Regulatory Considerations

SOAP notes generated by Lyrebird fall under the same regulatory framework as any Lyrebird output. The Australian Privacy Principles apply to the processing of patient data. Lyrebird processes and stores all data on Australian servers, so APP 8 offshore-transfer disclosure does not apply. Patient consent is required before the scribe is used, consistent with the TGA's August 2025 guidance on digital scribes.

Next Steps

To trial Lyrebird directly, book a demo. Lyrebird Free is available for free to Best Practice clinics.