AvodahMed Ambient Scribe Provider Best Practices

SOAP Note

Section 

What’s Included 

What’s Excluded 

Optimal Language

Subjective 

A paragraph summary of the patient's chief complaint (CC) or presenting problem leveraging the OLDCARTS methodology 

● OLDCARTS = Onset, Location, Duration, 

Characterization, Alleviating/Aggravating, 

Radiational, Temporal, Severity 

● A list of symptoms, conditions or experiences reported by the patient 

● Description of the chronological progression of the chief complaint 

● Key points from the conversation between the clinician and the patient

● Test results 

● Physical examination findings 

● Clinician interpretations

“How are you feeling today” 

“What brings you in today” 

“When did this start” 

“Where are you feeling it” 

“Has anything helped” 

“When is it worse” 

“What makes it worse” 

“How would you describe it” 

“How would you rate your pain from 0 to 10”

Objective 

A paragraph summary summarizing measurable findings and observations made by the provider. ● Physical examination findings, lab results, imaging, diagnostic data 

● Clear and objective insights made by the clinician ● Quantitative values like vitals and diagnostic test results

● Patient-reported symptoms 

● Provider interpretations

“I’ll have you sit on this table” 

“Let’s take a look at that” 

“I’m going to check a few things” 

“Let’s check your range of motion” 

“I’m going to pull up your report” 

“Let’s look at your test results”

Assessment & Plan

● Problem list, diagnosis, differential diagnosis o Diagnoses should include the ICD-10 code if it is available 

● Provider’s medical judgment and analysis of the patient’s condition 

● Risk factors and considerations for diagnosis ● Recommended testing, medications, referrals to specialists, patient education 

● Follow-up care instructions and next steps ● Treatment recommendations and expected outcomes 

● Referrals to specialists

● Lab values, prescriptions 

● Patient’s history, examination findings

“Based on what we’ve found, I’m diagnosing you with…” 

“This may be due to [condition]; we’ll confirm with some additional testing.” 

“I’m going to prescribe…” 

“I’d like to refer you to a specialist for…” “Let’s start you on [medication/treatment] and see how you respond.” 

“You’ll need to follow up in [X days/weeks] to monitor progress.” 

“Here’s what I recommend as the next step…”

Clinical Note

Section 

What’s Included 

What’s Excluded 

Optimal Language

Chief Complaint (CC)

This is the patient's primary reason for the visit. This is short and concise.

● Test results 

● Physical exam findings 

● Clinician interpretations 

● Treatment plans 

● Detailed medical history

“What brings you in today” 

“How are you feeling” 

“What symptoms have you been experiencing”

History of 

Present Illness

Paragraph format delivering a detailed and 

chronological summary of the patients reported symptoms 

● Onset, duration, severity, characterization, aggravating/alleviating factors for their chief complaint 

● Any associated symptoms and their timeline ● Past treatments and their effectiveness

● Provider assessments, unrelated past medical history

“When did this start” 

“How long has this been going on” 

“Where are you feeling it” 

“Has anything helped” 

“When is it worse” 

“How would you describe it” 

“How would you rate your pain from 0 to 10”

Vitals 

A list of the patient's vital signs as explicitly stated in the transcript, using standardized abbreviations and a consistent format. 

● Temperature, blood pressure, heart rate, oxygen saturation if mentioned 

● Other measurable physiological data if mentioned (e.g., weight, BMI, height)

● Chief Complaint 

● Provider assessments

“Let’s check your blood pressure” 

“Heart rate is…” 

“Your temperature is…” 

“What’s your height and weight”

Medication and Dosage

A list of all medications the patient is currently confirmed to be taking, including dosage, frequency, and route of administration if explicitly stated 

● List of prescribed medications with names, dosages, and frequency. 

● Route of administration (e.g., oral, IV, inhaled, topical). 

● PRN (as needed) medications and their 

indications.

● Expired or discontinued medications ● OTC medications unless clinically relevant

“What medications are you currently on” “You’re still taking…” 

“Any changes in your medications”

Past Medical 

History

A list of any previous medical conditions explicitly stated in the encounter with the patient. 

● Chronic conditions

● Family medical history 

“What is your medical history? “ 

“Do you have any current medical 

conditions?”

● Prior illnesses 

● Relevant medical diagnoses to the patient

“Do you have any past medical conditions?”

Past Surgical 

History

A list of any previous surgical procedures explicitly stated in the encounter 

● Previous surgeries with approximate dates (if available) 

● Any complications or relevant post-surgical outcomes

● Minor procedures unless they have clinical significance

“Anything else you’ve been treated for” “ What surgeries did the patient have in the past?” 

“ What are their approximate dates?” “ What was the medical condition the surgery was for?”

Allergies 

A list of any allergies explicitly stated in the encounter and the potential impacts 

● Documented drug, food, and environmental allergies 

● Severity and nature of allergic reactions (e.g., anaphylaxis, rash)

● Non-allergic intolerances unless clinically significant

“Do you have any allergies?” 

“Do you have any environmental allergies? “Do you have any medication allergies?” “Do you have any food allergies?”

Family History 

A list of any relevant family medical history explicitly stated in the encounter, including chronic conditions, genetic disorders, or other significant health issues affecting immediate family members 

● Patient’s immediate family with acute or chronic medical conditions 

● Other conditions that run in the patient’s family

● Distant relative or friends illnesses 

“Does anyone in your family have…” 

“Any family history of…”

Social History 

A list of any relevant social history explicitly stated in the transcript, such as substance use living situation, occupation, marital status, and family or social support 

● Smoking, alcohol, and drug use history (type, quantity, duration) 

● Occupational and lifestyle factors impacting health ● Relationship status, occupation, diet, exercise

● Non-health-related personal details 

“Do you smoke or drink” 

“What do you do for work” 

“Do you workout” 

“How often do you exercise” 

“Do you use/consume any other recreational drugs or have a history of substance abuse”

Review of 

Systems (ROS) Alterations

A structured list capturing the patient's responses to yes/no questions during the Review of Systems (ROS) ● Split by symptoms present and absent for positive or negative responses to specific review questions asked by the provider 

● Systematic review of body systems to identify symptoms not previously mentioned

● Diagnoses or provider interpretations ● Objective findings from the physical exam ● Past medical history unless directly relevant to current symptoms

“Any chest pain or shortness of breath” “Any fevers, chills, or recent weight changes” “Any nausea, vomiting, or diarrhea” 

“Any headaches or dizziness”

● Patient-reported symptoms categorized by system (e.g., cardiovascular, gastrointestinal, neurological) ● Any new symptoms or notable changes in existing symptoms

Physical 

Examination

A structured list detailing any objective findings or testing measurements explicitly obtained during the patient encounter, such as blood pressure, heart rate, respiratory rate, and other examination findings. 

● Findings categorized by organ systems (e.g., cardiac, pulmonary, neurological, musculoskeletal, gastrointestinal, dermatological) 

● Specific details about observed abnormalities or pertinent negatives (e.g., "Lungs clear to 

auscultation bilaterally," "No edema in lower extremities") 

● Inspection, palpation, percussion, and 

auscultation findings where relevant

● Imaging/diagnostic/lab results 

● Vitals qualitative measures, subjective symptoms reported by the patient (these belong in the HPI or ROS sections) 

● Interpretations, diagnoses, or treatment plans

“Let’s take a look at…” 

“Lungs sound…” 

“Your heart sounds…”

Test Results 

A list that summarizes any test results explicitly stated in the encounter, including laboratory tests, imaging findings, and other diagnostic results 

● Recent lab values and imaging reports relevant to the visit 

● Key numerical values (e.g., WBC count, glucose levels) and interpretations 

● Imaging and relevant results 

● Other diagnostic tests and relevant results

● Old or unrelated test results 

“Let’s go over your bloodwork” 

“Your cholesterol looks…” 

“On your x-rays I saw…” 

“Your CT showed…”

Assessment and Plan

A fixed format that should contain both a narrative and a list for each diagnosis discussed 

Example: 

● Diagnosis 1 

● Narrative sentences – path of plan summary o Plan 

▪ List -path: assessment & plan problems plan ▪ If no data: “No plan captured” 

o Goals 

▪ List - path: assessment and plan goals 

▪ If no Goals, do not show Goals 

● Diagnosis 2…

● Any past diagnosis, assessment and plan 

“Based on what we’ve found, I’m diagnosing you with…” 

“This may be due to [condition]; we’ll confirm with some additional testing.” 

“I’m going to prescribe…” 

“I’d like to refer you to a specialist for…” “Let’s start you on [medication/treatment] and see how you respond.” 

“You’ll need to follow up in [X days/weeks] to monitor progress.” 

“Here’s what I recommend as the next step…”

Referral Note

Section 

What’s Included 

What’s Excluded 

Optimal Language

Referral Specialty 

A list that specifies the specialty for each referral as explicitly stated in the encounter.

● Inferred specialties 

"Referring you to a Cardiology specialist…" “Sending you to a Neurologist…" 

“Let’s get you in to see an endocrinologist..” “We’ll set you up with dermatology…”

Reason for 

Referral

Paragraph formatted description of the reason for referral explicitly stated in the encounter.

● Inferred reasons or vague descriptions 

“Referring you to a cardiologist because…” ““We need a neurologist to assess your...” “You’ll see oncology because…”

Treatment 

provided to Date

A list detailing treatments explicitly provided to date as stated in the encounter.

● Inferred treatment plans or unclear activities and actions

“Patient has been taking Metformin 500mg twice daily.” 

“Started on topical steroid cream last week.” “Completed 7-day course of Amoxicillin.” “Underwent physical therapy for 6 weeks with limited improvement.” 

“Tried over-the-counter NSAIDs with mild relief.”

Requested Action from the 

Specialist

A list specifying actions explicitly requested from the specialist as stated in the encounter.

● Inferred actions or vague recommendations 

"Perform cardiac catheterization” 

“Please evaluate for surgical candidacy.” “Assess for hormonal imbalance and initiate management if indicated.” 

“Rule out autoimmune causes of....” 

“Perform diagnostic...” 

“Please provide treatment recommendations for...”

Follow-up 

Instructions

Paragraph formatted description of the follow-up instructions explicitly stated in the transcript

● Inferred actions or unclear follow-up plans 

"Schedule follow-up with cardiology in two weeks” 

“Return to this office after MRI and ortho consultation.” 

“Follow up with me in 2 weeks after visit.” “Please bring the specialist's 

recommendations to your next visit.”