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One of the most important parts about effectively treating patients in a healthcare facility is the precise recording of benchmarks and tracking the progress of treatment. Communicating important medical information effectively is essential to ensuring patients receive the best healthcare possible. This is why many clinicians choose to use the SOAP (subjective, objective, assessment, and plan) notes to organize patient information during or after visits.

Structuring their notes in this manner ensures that information isn’t lost or forgotten, and the SOAP template is easy to follow so that the patient’s healthcare journey is succinctly documented at all stages. So how does AI fit into all this, and is it a beneficial addition to improving patient care?

In this article we’re covering that and more, including:

• Why SOAP notes are important
• The benefits of using AI for SOAP notes
• The best AI for SOAP notes

Why SOAP notes are important (and where AI fits in)

Tracking patient progress is important in order to give them the best treatment

As a clinician, you always want to provide the best care for your patients, no matter what your speciality is. Keeping accurate patient files, especially with SOAP notes, can help you not only track how they have been doing while in your care, but you also have an easy way to share information. 

There’s a reason why physicians use the SOAP format as they provide a variety of benefits such as:

• Records patient treatment details. This is perhaps one of the main reasons why SOAP notes are a good idea, as it gives the doctor a designated place to record all that goes on while treating the patient. Here they can relate why the patient is visiting them, their vitals, and then make an assessment about their complaints. Including an ongoing plan for the patient once they leave lets the physician (or any other clinician) know exactly what took place and the treatment that was recommended.

SOAP notes are also one of the best ways to keep patient files organized and streamlined, so you can easily find dates, a diagnosis, treatment options, medication, and any other pertinent information.

• Tracks progress. You can use SOAP notes to track the progress of the patient’s treatment, and whether or not their complaints have been alleviated. Having an accurate timeline of events and benchmarks makes it easier to record improvements and setbacks alike. It’s impossible to remember everything about visits from all your patients, and with well-transcribed SOAP notes, doctors can gleen what the status is and where the patient is right now. This is especially helpful if they’re seeing a long-term patient and there are years or months of SOAP notes.

• Provides a way to share information with other clinicians. Oftentimes, a patient doesn’t just see one physician, but rather has a whole team of clinicians working on their treatment plan. If they are seeing multiple doctors in one location, well-organized SOAP notes allow the physician that is present with them to know everything about what’s going on with a particular patient, no matter if this is the first or the 10th time they’ve seen them. 

Having a professional SOAP notes also allows for ease in sharing patient data with those doctors that are outside of your practice. If a patient has been seen in an orthopedic office, transferring any SOAP notes to their physical therapist can make a world of difference and gets everyone on the same page.

• Information is available for insurance companies. In addition to sharing SOAP notes with other providers, they may also be shared with insurance companies if they are agreeing to pay for a specific treatment. Insurance may want to see the details of the patient diagnosis and what the treatment plan entails. SOAP notes are easy to transfer and can give these representatives a better idea of what exactly is going on with the patient’s treatment plan.

• Provides reference points during previous visits. There’s no way for a clinician to remember everything that’s happened in past visits with their patients, which is why SOAP notes are so helpful to getting them up to speed quickly. It may have been months or even years since they’ve seen the patient, and a quick review of SOAP notes will give them a good idea of where the patient stands right now. They may also have come in before with the same complaint, and reviewing the notes to see what worked in the past is a great way to fix the problem and determine if there’s a pattern to what’s causing the issue. 

How can AI assist with SOAP notes?

SOAP notes are so helpful to clinicians, but they’re only as good as the information that’s written in them. Most physicians are busy and see a variety of patients on any given day. Sometimes it’s difficult to input all the SOAP information after the visit, so they may find themselves doing it at the end of the day or off the clock. This takes up a lot of time, which could be better spent caring for patients or doing other necessary tasks. Artificial intelligence has been slowly gaining ground in the healthcare field, and it can not only help as a diagnostic tool or assist with procedures, but it can make the day to day life of a provider a little easier.

Lots of facilities have been trying out the idea of using AI to assist as a scribe during patient appointments and with SOAP notes. This would ideally free up the doctor to turn their attention to other important matters while the AI takes care of the time consuming, but necessary, task of transcribing accurate notes.

The benefits of using AI for SOAP notes

What are some of the advantages of using AI to input SOAP notes?

We know that using SOAP notes has a lot of benefits, but the truth is sometimes they are not transcribed as accurately or as clearly as they should be. This is especially true if there are multiple physicians working as a team to provide care for a patient. There may be inconsistencies in the information, and different clinicians can have varying documentation styles and weigh content importance to contrasting degrees. 

AI may be able to help with this situation, so that information is communicated correctly and is easy to share. By harnessing the power of natural language processing coupled with the ability to link up to EHR systems and other databases, AI can fill out necessary fields with the correct information.

Some of the top benefits of AI for SOAP notes include:

1. Increase in efficiency

Physicians are always looking for better ways to increase their efficiency without reducing the quality of patient care. Typing out SOAP notes is essential to keeping an accurate record of the patient and their treatment, but they can be time consuming, which may cause some to rush through them. With the help of AI, information can be inputted into the SOAP note in real time as it “listens” to the doctor/patient conversation. 

Using an automated system to create SOAP notes frees up the doctor to not worry about missing some key information that should be in the note, and they can really be present with the patient. 

2. Everything is standardized

Physicians learned to document patient information in a variety of ways and can lead to inconsistencies in SOAP notes, which is the last place you’d want this. AI can standardize how the information is inputted, and it will follow a template so that the data is put in the same place each time. This continuity can help eliminate variations on style and content, so that each time the right information is always put in. Having a standardized way to create these notes ensures any member of the healthcare team can review them and know exactly where the patient stands.

3. Better accuracy

Along with a consistent template and style, AI has the ability to analyze information from a variety of sources, not just the language from the visit. It can pull vast amounts of information quickly from EHR systems and other records and ensure that it makes it into the SOAP note. This creates a more comprehensive note, and reduces the chance that something is omitted or an error is made. While a doctor will still review the SOAP note for accuracy, using an automated process makes the likelihood of mistakes lower.

4. Easy access to crucial patient information

It’s important to have patient information easily available so it can be pulled up and referenced at any time. Pulling up the SOAP notes on their computer or tablet in real time allows doctors to have all the information they need at hand to make better decisions regarding patient care. Since it is all streamlined, they won’t have to worry about deciphering handwriting or shorthand, ensuring the patient data is always clear and understandable. 

5. Can easily be shared among providers

As we mentioned, it’s crucial for SOAP notes to be shared among members of a patient’s healthcare team. Having everything consolidated and stored in one place makes this very easy to do. Clinicians can pull up past notes on their tablet or computer, and no matter who entered the notes, they’re available to be shared and seen by any individual that is assisting with the care of the patient. AI helps make this level of coordinated care possible.

6. HIPAA compliant and secure

It’s essential that patient data is securely stored in the case of a data breach or cyber attack, and any system that accesses this information should be HIPAA compliant. Most AI scribes that use natural language processing to create these notes do not store the information. When it is sent to the patient’s EHR, that data is encrypted both when it is in motion and when it’s at rest. This is reassuring to know and increases both patient and physician confidence that the data is protected.

7. Streamlines workflows

Having SOAP notes filled in by AI takes away a time-consuming task from physicians, which can interrupt their day or create more work after hours. When the notes are updated in real time, it allows the provider to keep moving so they can attend to other important responsibilities. There is no more stopping to put information in, keeping the facility moving smoothly. 

Are there limitations for AI written SOAP notes?

Like all AI systems, there are some limitations, as the technology is still new. Many facilities have already deployed this technology and have seen a reduction in physician burnout and an increase in patient satisfaction. However, it’s important to know the limitations of AI, so it can be what it was designed to be, a supplement and not a replacement for clinician knowledge. Make sure to keep the following in mind:

• AI SOAP notes should still be read over by a physician to ensure accuracy
• There still maybe errors in the notes, which is why human eyes on SOAP notes is still important
• The AI learns more and increases accuracy when it is used consistently

What is the best AI for SOAP notes?

There are lots of AI scribes out there that can help free up physician time, but make sure you do your research and find one that is HIPAA compliant, fits the scale of your healthcare facility, and will work with your budget.

Consider checking out:

• Tali AI
• Freed AI
• SOAP Note AI

Can AI help with your SOAP notes?

AI has proven itself to be a useful tool to increase efficiency and streamline workflow processes. While it does have its limitations, it can contribute to improving patient experience and give clinicians more time to be with their patients to listen, assess, and create the right treatment plan for their situation.