# SOAP note: format, example, template and how to review one > What goes in each part of a SOAP note, how progress notes are written and billed, a worked example, a SOAP note template and a method for reviewing notes. Canonical page: https://medrecords.ai/guides/soap-note/ --- New — **Missing Records Detection:** flags every visit, provider, and date missing from the file. [See how →](https://medrecords.ai/product/missing-records-identification/) Record anatomy, September 2026. 10 chapters. ## SOAP note: what goes in each part and how to read a progress note For nurses, students, legal nurse consultants, attorneys and claims reviewers. You get the 4 parts field by field, the APSO and nursing variants, the federal and billing rules behind progress notes, what copied notes look like, a worked example, a SOAP note template and a review log. By [Ahmed Jemaa](https://medrecords.ai/authors/ahmed-jemaa/), Co-Founder and CEO, Medrecords AI. Published 26 September 2026. A SOAP note is a progress note written in 4 parts: Subjective (what the patient reports), Objective (exam findings, vital signs, labs and imaging), Assessment (the clinician's diagnosis or impression) and Plan (tests, treatment and follow-up). It comes from Lawrence Weed's problem-oriented medical record of the late 1960s and is still the default structure for daily progress notes in clinics and hospitals. Most of a patient's chart is data: vital signs, lab values, medication times. The progress note is where a clinician says what they made of it. In a claim or lawsuit that makes the SOAP note the place to find what the doctor knew, what they thought it meant and what they decided to do, on each day of care. It is also the part of the record most often copied forward from the day before. This guide is built from Lawrence Weed's 1968 articles in the New England Journal of Medicine, the hospital medical records rule at 42 CFR 482.24, the CMS evaluation and management booklet MLN006764 (May 2026), an APSO adoption study at UCHealth (American Journal of Accountable Care, 2017), a study of where progress note text comes from (JAMA Internal Medicine, 2017), an HHS Office of Inspector General report on EHR program integrity (2014), ONC guidance on USCDI and information blocking, and an ambient AI scribe rollout report (NEJM Catalyst, 2024). The worked example is hypothetical. Nothing here is legal or medical advice. 8 numbers ### The progress note in 8 numbers 4 parts Subjective, Objective, Assessment, Plan, written per problem Weed, NEJM, 1968 46% of the text in a typical inpatient progress note was copied Wang et al., JAMA Intern Med, 2017 18% of that text was typed by hand; the other 36% was imported by the EHR Wang et al., JAMA Intern Med, 2017 84.5% of outpatient notes reviewed at 1 health system used APSO order, Assessment and Plan first Sieja et al., AJAC, 2017 2023 since January 1, most E/M visit levels are chosen by medical decision making or total time CMS MLN006764, May 2026 8 clinical note types in USCDI version 1, progress notes among them ONC USCDI v1 303,266 patient encounters assisted by an ambient AI scribe in its first 10 weeks at 1 medical group Tierney et al., NEJM Catalyst, 2024 5 years minimum a hospital keeps records, notes included 42 CFR 482.24(b)(1) Chapter 1 Everyone ### What a SOAP note is A SOAP note is a way of writing a progress note so every reader finds the same things in the same place. S is what the patient says. O is what the clinician observes and measures. A is what the clinician concludes. P is what happens next. The order runs from evidence to judgment to action, which is why it has lasted. The structure comes from the problem-oriented medical record that Lawrence Weed described in 2 articles in the New England Journal of Medicine in 1968, "Medical records that guide and teach." Weed's point was that a chart organized by source (all the labs here, all the nurses' notes there) hides the doctor's reasoning. He proposed a numbered problem list for each patient and a note for each problem that showed the data, the interpretation and the plan. SOAP is the note format that came out of that idea. Today "SOAP note" and "progress note" are often used as if they meant the same thing. They do not. A progress note is a type of document: the daily or visit-by-visit entry that records how the patient is doing. SOAP is 1 way to structure it. A hospitalist's daily note, a physical therapist's session note, a counselor's visit note and a primary care follow-up can all be progress notes in SOAP form, or in APSO, DAR or narrative form. #### Terms you will meet Progress noteThe dated entry that records the patient's course between admission and discharge, or between visits. Physicians, nurse practitioners, physician assistants, nurses and therapists all write them. Problem listThe numbered list of active and resolved problems. In a problem-oriented note, each assessment and plan maps to a problem on it. Chief complaint (CC)A short statement of why the patient is being seen, usually in the patient's own words. It opens the Subjective section. HPI and ROSHistory of present illness and review of systems. The patient's story of the problem and a checklist of symptoms by body system. MDMMedical decision making. The billing measure of how complex the Assessment and Plan were. APSOThe same 4 sections with Assessment and Plan moved to the top. AddendumA later entry attached to a signed note, with its own date, time and signature. It adds to the note; it should not replace it. Copy forwardAn EHR function that carries yesterday's text into today's note. Useful for stable history, risky for exam findings and assessments. If you remember one thing SOAP is a structure: evidence first, then judgment, then action. A progress note is the document. Most progress notes use some version of it. Chapter 2 Everyone ### The 4 parts of a SOAP note, field by field The mock note below is a hospital day-2 progress note. The layout is invented; every EHR's note template differs. The 7 marked parts appear on almost all of them. Progress note, hospital day 2 Hypothetical Patient B, 06/11/2026, 07:40, general medicine Header — Author, credential, service, date and time of service, date and time signed1 S — "Breathing is a little better." Cough with yellow sputum. Slept 4 hours. No chest pain2 O — T 37.9, HR 96, BP 128/74, RR 22, SpO2 93% on 2 L. Crackles right base. WBC 14.1 (was 16.8). Chest X-ray: right lower lobe opacity3 A — 1. Community-acquired pneumonia, right lower lobe, improving. 2. Type 2 diabetes, glucose 180s4 P — 1. Continue ceftriaxone and azithromycin day 2 of 5; wean oxygen to SpO2 over 92%. 2. Increase basal insulin 10%; recheck morning glucose5 Signature — Electronically signed, Dr. D, 06/11 09:156 Addendum — 06/11 16:20: SpO2 89% on 2 L at 15:50, oxygen increased to 4 L, repeat X-ray ordered, Dr. D7 HYPOTHETICAL 1. 1 **Header and timestamps** There are usually 2 times: when the patient was seen and when the note was signed. A gap of hours is normal. A note signed days later, or after the patient died or was transferred, needs a closer look. 2. 2 **Subjective** The patient's words, symptoms and history since the last note. Quotation marks usually mean the patient's own words. Check it against the nursing notes for the same hours. 3. 3 **Objective** Vital signs, exam, labs and imaging. Much of it may be pulled in by the EHR. Each value has a time in another part of the chart; match them. 4. 4 **Assessment** The clinician's conclusion for each problem: the diagnosis and whether it is better, worse or unchanged. This is the section that shows what the clinician knew and believed that day. 5. 5 **Plan** The orders, tests, consults and follow-up that should flow from each assessment. Every plan item should have a matching order. 6. 6 **Authentication** A signature that ties the note to 1 person. Resident notes often carry an attending's co-signature or attestation as well. 7. 7 **Addendum** A dated, signed addition. It should read as new information, not as a rewrite of what was known at 07:40. #### What belongs in each section | Section | What goes there | What a reviewer checks | | --- | --- | --- | | Subjective | Chief complaint, history of present illness, symptoms, review of systems, relevant history, medications the patient reports, what the patient or family says | Does it match the nursing notes and the patient's later testimony? Is it word for word the same as yesterday? | | Objective | Vital signs, physical exam by system, intake and output, lab results, imaging and other test results, device data | Do the numbers match the flowsheet and lab reports for the same time? Is the exam consistent with other clinicians' exams that day? | | Assessment | Diagnosis or differential for each problem, severity, trend, response to treatment | Does the assessment follow from the Objective data? Does it mention the abnormal values, or skip them? | | Plan | Diagnostic tests, medications, procedures, consults, patient education, disposition and follow-up | Is there an order for each item? Was each plan item done, and when? | Abbreviations are dense in all 4 sections. "NAD" (no acute distress), "RRR" (regular rate and rhythm), "CTAB" (clear to auscultation bilaterally) and "WNL" (within normal limits) are exam shorthand that often arrives by template. Our guide to [medical abbreviations for legal professionals](https://medrecords.ai/guides/medical-abbreviations-for-legal-professionals/) covers how to read them without guessing. If you remember one thing Subjective and Objective are claims about facts that other records can confirm. Assessment and Plan are claims about the clinician's thinking. Check the first 2 against the chart and the last 2 against the first 2. Chapter 3 Deciding ### SOAP, APSO and the nursing formats SOAP puts the conclusion at the bottom. In a long EHR note with imported labs and templated exams, that means scrolling past pages of data to find out what the author thought. APSO moves Assessment and Plan to the top and leaves S and O below as supporting data. In June 2013 the Association of Medical Directors of Information Systems published guiding principles for electronic documentation that included notes with Assessment and Plan at the top. The same year, Lin and colleagues reported in JAMA Internal Medicine that 83% of outpatient clinicians surveyed found APSO faster to write than SOAP and 81% found it easier to find data in. The largest adoption study came from UCHealth in Colorado, which moved to APSO across 1 academic hospital, 4 community hospitals and more than 100 clinics. Sieja and colleagues reviewed 894 outpatient and 1,057 inpatient notes in 2014: **Note format in use after an APSO rollout** — share of notes reviewed — Sieja et al., American Journal of Accountable Care 5(1), 2017 Where a health system switches, most notes follow. 80% of the 564 clinicians who answered the survey were satisfied or very satisfied with APSO as authors and readers. For a reviewer, the order changes where to look, not what to look for. Nurses often use other structures for narrative notes. The 3 you will see most: | Format | Parts | Where you see it | | --- | --- | --- | | SOAP / SOAPIE | Subjective, Objective, Assessment, Plan, plus Intervention and Evaluation in the longer form | Physician and advanced practice notes; some nursing notes | | APSO | Assessment, Plan, Subjective, Objective | Health systems that reordered their EHR templates | | DAR (focus charting) | Data, Action, Response, under a focus heading | Nursing narrative notes | | PIE | Problem, Intervention, Evaluation | Nursing care plans and notes | | SBAR | Situation, Background, Assessment, Recommendation | Nurse-to-physician calls and handoffs; often charted as a note after the call | | Narrative | Free text in time order | Older paper charts, event notes, late entries | Many hospitals pair narrative nursing notes with flowsheets and chart only exceptions in the note. Our guide to [charting by exception](https://medrecords.ai/guides/charting-by-exception/) covers how to read that pairing. If you remember one thing SOAP, APSO, DAR and SBAR hold the same kinds of facts in a different order. Learn the order the facility used, then read every note the same way. Chapter 4 Everyone ### The rules behind progress notes No federal rule requires the letters S, O, A and P. The rules say what the record must show, and progress notes are how clinicians show it. For a hospital that takes Medicare, the medical records Condition of Participation sets the purpose of the whole record: "The medical record must contain information to justify admission and continued hospitalization, support the diagnosis, and describe the patient's progress and response to medications and services." The same section requires every entry to be "legible, complete, dated, timed, and authenticated" by the person responsible, lists the results of all consultative evaluations and the documentation of complications and unfavorable drug reactions among the required contents, and requires the record to be completed within 30 days after discharge. Hospitals keep records for at least 5 years (482.24(b)(1)); many states require longer. | Rule | What it requires | What it means for a progress note | | --- | --- | --- | | 42 CFR 482.24(c) | Records justify the stay, support the diagnosis and describe progress and response to treatment | Daily notes are the main evidence that the stay and the treatment were needed | | 42 CFR 482.24(c)(1) | Entries legible, complete, dated, timed and authenticated | A note without a time or a signature is incomplete on its face | | 42 CFR 482.24(c)(4)(iii) and (iv) | Consult results; complications, hospital-acquired infections and unfavorable drug reactions | If a complication happened, a progress note should name it | | CMS MLN006764 | Visit level chosen by MDM or total time; if time, document start and stop or total time | The note's length and exam detail do not set the billing level | | Information blocking rules | Since April 5, 2021, providers may not block patients' access to their electronic health information without an exception | Patients can read their progress notes, usually in the portal, often within days | [](https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-G/part-482/subpart-C/section-482.24) [](https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-G/part-482/subpart-C/section-482.24) [](https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-G/part-482/subpart-C/section-482.24) [](https://www.cms.gov/files/document/mln006764-evaluation-management-services.pdf) [](https://healthit.gov/information-blocking/) #### What billing rules say about the note The CMS booklet on evaluation and management services, updated May 2026, sets the current Medicare approach. Since January 1, 2023, for most E/M visit families, the visit level is chosen by the level of medical decision making or by the total time spent. The history and exam must be "medically appropriate" and must meet the code descriptors, but they do not affect the level. When time is used, the note should record start and stop times or the total time. The booklet also defines the chief complaint as a short statement of the reason for the encounter, "usually stated in the patient's own words." That change matters for reading notes written before and after 2023. A long templated exam in a 2019 note may have been there partly to support the billing level. In a 2024 note it adds nothing to the level, and a reviewer can weigh it as documentation of what was examined, not as billing padding. Our guide to [getting medical records for a lawsuit](https://medrecords.ai/guides/how-to-get-medical-records-for-a-lawsuit/) covers requesting the billing records that sit beside the notes. #### Open notes The 21st Century Cures Act information blocking rules took effect on April 5, 2021. Until October 5, 2022 they covered the data elements in USCDI; since October 6, 2022 they cover all electronic health information. USCDI version 1 lists 8 clinical note types: consultation note, discharge summary note, history and physical, procedure note, progress note, imaging narrative, laboratory report narrative and pathology report narrative. Psychotherapy notes kept separately by a mental health professional are excluded. Patients now read progress notes, sometimes before the next visit. That has changed how some clinicians write the Subjective and Assessment sections, and it gives a reviewer another source: portal messages in which a patient disputes what a note says. If you remember one thing The rules ask the record to show progress and response to treatment, dated, timed and signed. The format is the facility's choice. The completeness is not. Chapter 5 Deciding ### Copied, cloned and templated notes An EHR lets a clinician start today's note from yesterday's, pull in labs and vital signs automatically, and insert a normal exam with a phrase. All 3 save time. All 3 can put text in a note that does not describe that day. The best-known measurement comes from the University of California San Francisco, where Wang, Khanna and Najafi analyzed the source of every character in inpatient progress notes on a general medicine service from January to August 2016: **Where the text in an inpatient progress note came from** — 23,630 notes, 460 clinicians — Wang, Khanna and Najafi, JAMA Internal Medicine, 2017 Typical noteall authors 18% typed — 46% copied — 36% imported Residentsper note 11.8% — 51.4% copied — rest **Typed by hand — **Copied — **Imported by the EHR, or other Less than a fifth of a typical note was typed fresh. Residents typed 11.8% and copied 51.4%. On a printout, copied text and fresh text look the same. Payers noticed early. In 2014 the HHS Office of Inspector General reported that not all Medicare contractors could tell whether a provider had copied language or overdocumented in a medical record, and recommended that CMS give contractors guidance on EHR fraud risks and direct them to use providers' audit logs. The audit log is the record of who created, viewed and changed each note, and when. It is a separate system from the note itself. Our guide on [EHR audit trails in malpractice cases](https://medrecords.ai/guides/ehr-audit-trail-medical-malpractice/) covers how to ask for it. #### What copied text looks like on paper | Pattern | Example | Why it is a question | | --- | --- | --- | | Frozen Subjective | "Patient denies pain" on 4 days while nursing notes record pain scores of 6 to 8 | The note may not reflect a conversation that day | | Frozen exam | "Abdomen soft, nontender" word for word for 3 days before a surgical abdomen was found | The exam may not have been done, or not recorded | | Stale day count | "Post-op day 1" on the second and third days | A sign the whole note was carried forward | | Resolved problems still active | A Foley catheter "in place" after the removal order | The note contradicts orders and nursing records | | Imported values from the wrong time | Labs labelled "today" that were drawn the day before | The note may date a finding wrongly | | Assessment unchanged while data changes | "Improving" while temperature and white count rise | The central question: did the clinician see the change? | None of these proves poor care. Copied history is often accurate and a stable exam may be stable. But a frozen section is not evidence of a fresh assessment, and in a delayed-diagnosis case the day the note first changed is often the day the case turns on. If you remember one thing Compare each note with the day before it, section by section. The first day a section changes is usually the first day someone wrote it fresh. Chapter 6 Building ### Worked example: 4 days of progress notes **Hypothetical.** The patient, hospital, clinicians, times and pages are invented to show the method. It is not a real case or a customer file. A 59-year-old patient has a laparoscopic colon resection on 06/09/2026. The file holds physician progress notes (pages 201 to 212), nursing notes (pages 300 to 331), the vital signs flowsheet (pages 150 to 158), lab results (pages 180 to 186) and a CT report (page 190). **The progress notes for post-op days 1 to 4, beside the other sources** — hypothetical — Illustration Progress note review log, 06/10 to 06/13, hypothetical — 8 entries | Date | Section | Note says | Other source | Page | | --- | --- | --- | --- | --- | | 06/10 | A/P | "POD 1, doing well. Advance diet" | Consistent with nursing and vitals | 201 | | 06/11 | S | "Denies abdominal pain" | Nursing: pain 7 at 06:00 and 10:00 | 204, 312 | | 06/11 | A/P | "POD 1, doing well" (same as 06/10) | Date shows POD 2 | 204 | | 06/12 | O | "Afebrile. Abdomen soft, nontender" | Flowsheet: T 38.4 at 04:00; HR 112 | 207, 155 | | 06/12 | O | WBC not listed | Lab: WBC 17.9 at 05:10 (was 11.2) | 207, 183 | | 06/12 | Header | Service 07:30, signed 06/14 11:02 | After the CT and the return to surgery | 207 | | 06/13 | A/P | "Concern for anastomotic leak. CT now. Surgery aware" | CT 09:40: fluid and free air | 210, 190 | | 06/13 | Addendum | "Taken to OR 12:15" | Matches the operating room record | 211 | Gold rows: entries that need a question. Green row: the first note whose assessment changed. 8 entries, 5 questions. The notes for 06/11 and 06/12 carry text that the nursing notes, flowsheet and labs contradict. #### What each flag means 1. **"Denies abdominal pain" on 06/11.** The nursing notes chart pain of 7 at 06:00 and 10:00. The patient may have said something different to each person. The Subjective text is also identical to 06/10's, which suggests it was carried forward. 2. **"POD 1" on post-op day 2.** A stale day count is the clearest sign that a whole Assessment and Plan was copied. It does not prove the patient was not seen. 3. **"Afebrile" with a temperature of 38.4.** The fever was charted 3 hours before the note's time of service. Either the author did not look or the Objective text was not updated. 4. **A missing white count.** The value rose from 11.2 to 17.9 overnight and does not appear in the note. The question is whether the author saw it before signing. 5. **A note signed 2 days late.** Signed after the leak was found. A late signature is common and not wrong by itself, but the audit log can show whether the text changed between creation and signing. #### The same 4 days on 1 timeline **Every time-stamped source in order** — hypothetical — Illustration; pages refer to the hypothetical file 1. 06/10 08:00 **POD 1 note: doing well** Matches vitals and nursing notes. Note p. 201 2. 06/11 06:00 to 10:00 **Pain 7 twice** Nurse notes distension and nausea. Nursing p. 312 3. 06/11 07:45 **POD 2 note reads "POD 1, denies pain"** Identical to 06/10 in S and A/P. Note p. 204 4. 06/12 04:00 to 05:10 **T 38.4, HR 112, WBC 17.9** 3 abnormal values before rounds. Flowsheet p. 155; lab p. 183 5. 06/12 07:30 **Note: "afebrile, abdomen soft"** No mention of the fever or white count. Signed 06/14. Note p. 207 6. 06/13 07:20 **Assessment changes: possible leak** CT ordered. Note p. 210 7. 06/13 09:40 **CT: fluid and free air** Consistent with a leak. CT p. 190 8. 06/13 12:15 **Return to the operating room** Addendum to the day's note. Note p. 211 Read alone, the progress notes show a patient who was fine until 06/13. Merged with 3 other sources, the first abnormal signals appear on 06/11, 2 days earlier. ##### What a progress note can show When it was written fresh - What the clinician recorded as the patient's complaints that day. - Which findings the clinician documented and which were left out. - The clinician's working diagnosis and its trend. - What the clinician planned to do, to compare with the orders. ##### What it cannot show alone Where you need another record - That the text was written that day (the audit log shows creation and edits). - That the exam was done as charted (other clinicians' notes, testimony). - Whether the plan was carried out (orders, MAR, results). - What was said to the patient that the note left out. If you remember one thing Put the notes, the nursing record, the vital signs and the labs on 1 timeline. The gap between what the data showed and what the note said is usually the finding. Chapter 7 Building ### How to review progress notes, step by step The method below works for a 3-day stay or a 3-year course of outpatient visits. The order matters: know what the data showed before you read what the note concluded. 1. **Collect every note type.** Physician, advanced practice, resident, consult, nursing and therapy notes, with their addenda and attestations. Ask for notes in their final form and, if timing matters, the audit log. 2. **List the notes by time of service.** 1 line per note: date, time of service, time signed, author, credential, type. 3. **Build the data timeline first.** Vital signs, labs, imaging and medication times from their own records, not from the notes. 4. **Read each note against the data from the 12 hours before it.** Does the Objective section match? Does the Assessment mention the abnormal values? 5. **Compare each note with the one before it.** Mark sections that are identical, and any stale day count or resolved problem still listed. 6. **Match every Plan item to an order and a result.** A plan without an order, or an order without a plan, gets a line. 7. **Check signature timing.** Note any note signed after a key event: a transfer, a return to surgery, a death, a complaint. 8. **Log each question with a page cite.** So anyone can check it against the file. #### Is this note evidence of what the clinician knew? 1 **Is the section identical to the previous day's note?** NoGo to 2. YesTreat it as carried forward. Look for fresh text elsewhere in the note or in other records. 2 **Does the Objective section match the flowsheet and labs for the same hours?** YesGo to 3. NoLog the mismatch with both page cites. 3 **Does the Assessment address each abnormal value?** YesGo to 4. NoLog what was not addressed and whether the value was available before signing. 4 **Was the note signed before the next key event?** YesTreat the note as a record of that day's thinking. NoRequest the audit log to see whether the text changed before signing. ##### 1. SOAP note template A plain progress note structure. Adapt the sections to your setting and your facility's policy. PROGRESS NOTE Patient: [NAME / ID] Date of service: [DATE] Time: [TIME] Author: [NAME, CREDENTIAL] Service / setting: [UNIT OR CLINIC] Hospital day / post-op day / visit number: [N] S: SUBJECTIVE Chief complaint (patient's words): "[ ]" Interval history since last note: [ ] Symptoms and review of systems: [ ] Patient-reported medications, adherence, side effects: [ ] O: OBJECTIVE Vital signs (with times): T [ ] HR [ ] BP [ ] RR [ ] SpO2 [ ] on [ ] Intake / output: [ ] Exam by system: [ ] Labs (with collection times): [ ] Imaging and other results: [ ] A: ASSESSMENT (1 line per problem) 1. [Problem]: [better / worse / unchanged], because [data] 2. [Problem]: [ ] P: PLAN (1 block per problem, matching A) 1. [Tests, medications, consults, education, follow-up] 2. [ ] Disposition / next review: [ ] Time of service or total time (if billing by time): [ ] Signature: [NAME, CREDENTIAL] Signed: [DATE, TIME] ##### 2. Progress note review log 1 line per note. Keep the page cite in every line. PROGRESS NOTE REVIEW LOG Patient: [ID] Facility: [NAME] Dates: [FROM] to [TO] Date | Time of service | Time signed | Author, credential | Page | Same as prior note? (S / O / A / P, or none) | Objective vs flowsheet and labs (match / mismatch + page) | Abnormal values not addressed in Assessment | Plan items without an order or result | Signed after a key event? (event, time) | Question Example: 06/12 | 07:30 | 06/14 11:02 | Dr. E, MD | p. 207 | S same as 06/11 | "Afebrile" vs T 38.4 at 04:00 (p. 155) | WBC 17.9 at 05:10 (p. 183) not mentioned | None | Yes: signed after CT and return to OR | Was the WBC available at 07:30? Request audit log #### Before you rely on a set of progress notes - **Every note type is present** *Physician, resident, advanced practice, consult, nursing and therapy notes.* - **Addenda and attestations are attached** *With their own dates, times and signatures.* - **Time of service and time signed are both visible** *Some printouts show only 1. Ask for both.* - **Flowsheet and lab times are in hand** *To test the Objective section against the source.* - **Identical sections are marked** *Day by day, before you quote any of them.* - **Audit log requested where timing is disputed** *Creation, edit and signing times for the notes that matter.* 0 of 6 checked. If a note looks changed after the fact, the method shifts. Our guide to [altered medical records](https://medrecords.ai/guides/altered-medical-records/) covers late entries and edits, and the [medication administration record](https://medrecords.ai/guides/medication-administration-record/) guide covers checking a Plan against what was given. If you remember one thing Build the data timeline from the source records first. Then read each note against what was known in the hours before it was written. Chapter 8 Deciding ### AI scribes, AI review and the progress note AI now sits on both sides of the progress note. It writes some of them, and it reads others. #### Ambient AI scribes write the note An ambient AI scribe listens to the visit through a phone or room microphone and drafts the note for the clinician to edit and sign. The largest published rollout came from The Permanente Medical Group, which enabled the tool for 10,000 physicians and staff in October 2023. Tierney and colleagues reported the first 10 weeks in NEJM Catalyst: **Ambient AI scribe use in the first 10 weeks** — 1 medical group — Tierney et al., NEJM Catalyst, February 2024 Up to 303,266 encounters in 10 weeks, and 1 physician used it in 1,210. The tool did not retain audio recordings, so the edited note is the only record of the conversation. For a reviewer this changes 2 things. First, the Subjective section in a note written with a scribe may be a summary of a recorded conversation, edited by the clinician, rather than the clinician's own shorthand. Second, if the audio is not kept, nothing else captures what was said. Ask the facility whether an AI scribe was used for the visits in question, what its policy says about review before signing, and what, if anything, it retains. #### Where AI helps a reviewer The review in chapter 7 is mostly comparison: this note against yesterday's, this Objective section against the flowsheet, this Plan against the orders. On a long stay that means hundreds of notes. AI medical record review does the comparing well. A grounded system can pull every note into a dated list, place it on a timeline with the vitals, labs and nursing entries, and give every line a page-level citation back to the source, which turns a stack of notes into an AI medical chronology you can check. It has limits. A large language model (LLM) asked to summarize notes without citations can produce a fluent sentence that is not in the record; hallucination is the reason every line needs to point to its page. Scanned notes need OCR, and handwritten entries on older paper charts are harder for any model. A summary can also repeat copied text as if it were a fresh finding, which is why the reviewer, the human in the loop, reads the flagged days in the source. Medrecords AI works this way on the files you upload. It builds a [cited medical chronology](https://medrecords.ai/product/chronology/) with each dated note as its own entry linked to its page, so you can read day 2 and day 3 side by side. It routes each page through [OCR](https://medrecords.ai/product/ocr/) matched to its content, including [handwritten entries](https://medrecords.ai/product/handwritten-medical-record-extraction/). It answers questions like "every note that mentions abdominal pain, with the nursing pain score nearest to it" through [cited Q&A](https://medrecords.ai/product/qa/) and [record search](https://medrecords.ai/product/medical-record-search/), and it flags [records that should exist but were not produced](https://medrecords.ai/product/missing-records-identification/). Flags are signals, not verdicts. It does not decide whether a note was copied or whether care met the standard, and it does not retrieve records from providers. It runs under SOC 2 and HIPAA with a signed business associate agreement (see [security](https://medrecords.ai/security/) and [HIPAA](https://medrecords.ai/hipaa/) ). Self-Service bills 10 cents a deduplicated page, down to 5 cents at volume, duplicates free; Enterprise On-Prem is an annual license. If you are comparing tools, our guide to [medical record review](https://medrecords.ai/guides/medical-record-review/) covers what to ask any medical chronology software vendor. See how note review fits [medical malpractice](https://medrecords.ai/solutions/medical-malpractice/), [hospital nursing negligence](https://medrecords.ai/solutions/hospital-nursing-negligence-record-review/) and [legal nurse consultant](https://medrecords.ai/solutions/legal-nurse-consultants/) work. The offer #### See every progress note on 1 timeline, cited to its page. Book a demo on a file where the notes and the data disagree, then run your first case free on us. Every line comes back cited to its source page. You review, you revise, you sign. [Book a demo](https://medrecords.ai/demo/) [See the cited chronology](https://medrecords.ai/product/chronology/) Scheduling only. No records move from a public page. If you remember one thing AI can line up every note against the data in minutes, with a page on every line. A person still decides what a copied section or a missed value means. Chapter 9 Everyone ### Frequently asked questions What does SOAP stand for?Subjective, Objective, Assessment and Plan. Subjective is what the patient reports, Objective is what the clinician measures and observes, Assessment is the diagnosis or impression, and Plan is what happens next. Is a progress note the same as a SOAP note?Not quite. A progress note is the type of document that records the patient's course. SOAP is the most common way to structure it. Some progress notes use APSO, DAR or free narrative instead. Who invented the SOAP note?It grew out of the problem-oriented medical record that Lawrence Weed described in the New England Journal of Medicine in 1968, which organized each note by problem with data, interpretation and plan. What is an APSO note?The same 4 sections with Assessment and Plan first. Health systems adopted it so readers see the clinician's conclusions without scrolling past imported data. At UCHealth, 84.5% of outpatient notes reviewed used it after the rollout. What goes in the Objective section?Measurable findings: vital signs, the physical exam, intake and output, lab results, imaging and other test results. In EHR notes much of it is imported, so check each value's time against its source record. How do you write a good Assessment?1 line per problem, naming the diagnosis and whether it is better, worse or unchanged, with the data that supports that trend. An assessment that ignores an abnormal value in the Objective section is the most common gap reviewers find. Can patients read their progress notes?Yes. Since April 5, 2021, federal information blocking rules require providers to give patients access to their electronic health information, and progress notes are 1 of the 8 note types in USCDI version 1. Psychotherapy notes kept separately are excluded. How can you tell if a progress note was copied forward?Compare it with the previous day's note section by section. Identical text, a stale hospital or post-op day count, and problems listed after they resolved are signs. The EHR audit log shows when text was created and edited. Can AI write SOAP notes?Ambient AI scribes draft notes from the visit conversation for the clinician to edit and sign. 1 medical group reported 3,442 physicians using one in its first 10 weeks. The signing clinician remains responsible for what the note says. Can AI review progress notes for a legal case?It can line up every note against vital signs, labs and nursing entries and cite each line to its page. Whether a mismatch means the care fell short is a judgment a qualified person makes after reading the source. Is it HIPAA compliant to upload progress notes to an AI tool?It can be, with a vendor that signs a business associate agreement, holds a SOC 2 report and commits in writing not to train on your data. A consumer chatbot without a BAA is a different matter. Chapter 10 Everyone ### Sources and method Regulations and CMS guidance were read in full text from primary sources in September 2026, and quoted text is verbatim. Study figures come from the published papers. The mock note, patient, clinicians, times and pages in chapters 2, 6 and 7 are hypothetical. Product facts come from this site's product pages. Nothing here is legal or medical advice. - [Weed LL, "Medical records that guide and teach"](https://pubmed.ncbi.nlm.nih.gov/5637758/), New England Journal of Medicine 278(11):593-600 and 278(12):652-657, 1968: the problem-oriented medical record. - [42 CFR 482.24(b)(1), (c), (c)(1), (c)(4)(iii), (iv) and (viii)](https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-G/part-482/subpart-C/section-482.24): retention, record content, entry standards, consults and complications, completion within 30 days. - [CMS MLN006764, Evaluation and Management Services (May 2026)](https://www.cms.gov/files/document/mln006764-evaluation-management-services.pdf): visit level by MDM or total time since January 1, 2023; history and exam medically appropriate but not used for level; time documentation; chief complaint. - [Sieja A, Pell J, Markley K, et al., "Successful implementation of APSO notes across a major health system"](https://www.ajmc.com/view/successful-implementation-of-apso-notes-across-a-major-health-system), American Journal of Accountable Care 5(1), 2017: note format shares, survey of 564 of 3,170 clinicians, AMDIS 2013 and Lin 2013 findings. - [Wang MD, Khanna R, Najafi N, "Characterizing the source of text in electronic health record progress notes"](https://pmc.ncbi.nlm.nih.gov/articles/PMC5818790/), JAMA Internal Medicine 177(8):1212-1213, 2017: 23,630 notes, 18% typed, 46% copied, 36% imported. - [HHS OIG, OEI-01-11-00571 (January 7, 2014)](https://oig.hhs.gov/reports/all/2014/cms-and-its-contractors-have-adopted-few-program-integrity-practices-to-address-vulnerabilities-in-ehrs/): contractors and copied or overdocumented records; recommendation to use audit logs. - [ONC, information blocking](https://healthit.gov/information-blocking/) and [USCDI](https://isp.healthit.gov/united-states-core-data-interoperability-uscdi): applicability dates and the 8 clinical note types in version 1. - [Tierney AA, Gayre G, Hoberman B, et al., "Ambient artificial intelligence scribes to alleviate the burden of clinical documentation"](https://catalyst.nejm.org/doi/abs/10.1056/CAT.23.0404), NEJM Catalyst, February 21, 2024: rollout figures and audio retention. ### More guides - [**TBI imaging, diffuse axonal injury and DTI: the records that decide severity** — TBI imaging in court: why a normal CT does not rule out brain injury, how SWI and DTI get challenged, and the…](https://medrecords.ai/guides/tbi-imaging-diffuse-axonal-injury-dti/) - [**The eggshell plaintiff rule and pre-existing conditions: how prior records decide the case** — The eggshell plaintiff rule, aggravation and apportionment explained, what the defense looks for in prior…](https://medrecords.ai/guides/eggshell-plaintiff-pre-existing-conditions/) - [**Toxicology reports in litigation: how to read clinical and postmortem results without losing the case** — How to read a toxicology report for litigation: immunoassay screens versus GC-MS confirmation, serum alcohol…](https://medrecords.ai/guides/toxicology-report-litigation/) - [**Traumatic brain injury lawsuits: causation, long-term impact and the evidence that survives cross** — How a traumatic brain injury lawsuit is proven or defended from the records: causation attacks, post-concussion…](https://medrecords.ai/guides/tbi-causation-long-term-impact/) - [**UB-04 and CMS-1500: how to read the claim forms behind a medical bill** — What each box on a UB-04 and a CMS-1500 claim form means, the codes on them, a worked bill-to-record match…](https://medrecords.ai/guides/ub-04-and-cms-1500/) - [**What is a medical chronology?** — What a medical chronology is, what a good one includes, how it differs from a summary or narrative, who uses…](https://medrecords.ai/guides/what-is-a-medical-chronology/)