1. What is a SOAP note?
After every patient visit, a doctor has to write it up. The standard format is the SOAP note: what the patient Said, what the doctor Observed, the Assessment (the diagnosis, with the ICD-10 codes insurers and billing use), and the Plan (treatment, prescription, follow-up).
It's the legal record of the visit, the basis for billing, and what audits check. Today most of it is typed from memory, hours after the patient has left. This agent writes it during the visit instead.