SOAP Notes

What is a SOAP note?

A SOAP note is a structured clinical note with four sections. It gives clinicians a consistent way to record an encounter and understand someone else's documentation, supporting continuity between visits and team members.

Larry Weed developed the widely adopted SOAP note structure. NCBI's SOAP reference explains that it organises patient information and works as both a checklist and a cognitive framework for evaluating information and clinical reasoning.

S · Subjective

What the patient reports

The presenting complaint and history in the patient's own words: symptoms, timing, what makes them better or worse, and how they affect the person. This section records their experience without adding the clinician's interpretation.

O · Objective

What you measure and observe

Vital signs, examination findings, observations and results. These are facts you can measure or observe, recorded so another clinician can follow the evidence.

A · Assessment

Your clinical reasoning

The working diagnosis or problem list, relevant differentials, risk and how the subjective and objective findings support your thinking. This is where clinical judgement becomes explicit.

P · Plan

What happens next

Investigations, treatment, referrals, information provided, safety-netting and follow-up. It should be specific enough that the patient and the next clinician can understand what was decided, who is responsible and when it should happen.

Method

What an Australian clinical record still needs

SOAP is an organising format. It does not by itself make a record complete or compliant. The Royal Australian College of General Practitioners (RACGP) record standard and Australian Health Practitioner Regulation Agency (AHPRA) record guidance support this practical checklist:

• Make the record during the encounter or as soon as practicable afterwards. Keep it accurate, up to date, factual, objective, respectful and legible.
• Identify the date and time, the clinician who provided the service and, where relevant, where it occurred.
• Record the reason for the encounter and the relevant clinical history, medicines, allergies, examination findings, results and communications.
• Document the diagnosis or formulation where appropriate, the management plan, medicines prescribed or changed, information and advice given, and the expected review process.
• Make follow-up ownership and outstanding actions clear. Write enough for another practitioner to understand the record and continue care.

Professional and legal requirements vary by profession, setting, state or territory. Local record policy and profession-specific obligations still apply.

Using SOAP templates with Lyrebird

Our authenticated clinical notes workflow can capture an ambient consult, dictation or typed notes and produce a draft in SOAP, progress-note or a supported custom template. You review the whole draft, add any unspoken reasoning, edit inaccuracies or omissions, and sign off the final record.

With our Bp Premier integration, Lyrebird reads supported patient context from Bp Premier and writes clinician-finalised notes, documents and supported observations back to the correct patient file. Blood pressure and weight are specifically supported for structured observation write-back. Bp Premier remains the source clinical record.

What the current evaluation shows

A 16-week Gold Coast Hospital and Health Service trial evaluated Lyrebird, as identified in our current evaluation disclosure. The peer-reviewed paper reports the methods and results from 100 clinicians, 7,499 consultations and 19 outpatient specialties. Eighteen matched note pairs were scored using the Physician Documentation Quality Instrument-9: AI-generated notes averaged 37.06/40 and clinician-created notes 34.6/40. In a separate 21-pair comparison, the median ROUGE-1 F1 score was 0.58. The authors interpreted the overlap score as roughly 58% verbatim text reuse. It does not mean 58% of whole notes were accepted unchanged. The paper also reports that 47% of the 43 staff survey respondents had observed a hallucination at least once during the trial.

The study came from one health service, and its note-quality substudies were small. Its benefits and safety signals point to the same operating rule: AI output is a draft for clinician review, editing and sign-off.

Privacy and clinical responsibility

The public builder on this page must never receive real or identifiable patient information. Authenticated Lyrebird is a separate clinical service governed by our current privacy policy, which states that personal information is stored in Australia and also describes specific circumstances involving overseas access or processing.

The Office of the Australian Information Commissioner (OAIC) explains in the Australian Privacy Principles Guidelines that Australian Privacy Principle (APP) 8 can apply when an APP entity discloses personal information to an overseas recipient, including accountability in some circumstances. The Therapeutic Goods Administration (TGA) digital scribe guidance sets an expectation that a clinician gives the patient enough information to provide informed consent before using a digital scribe. Practices should apply the consent or notice process, privacy assessment and governance required for their specific workflow.

Common questions