8 Best Practices for Integrating AI into SOAP Note Documentation


Documentation is one of the most important services that medical professionals have to provide for their patients. In an industry with hundreds of millions of patients a year, the only way to effectively keep track of everything is by using effective documentation. However, this can take hours away from an already busy schedule, and for that reason, many people are turning to AI to help them with this task.

User-friendly interface

Having a user-friendly interface is crucial for being able to appeal to a wide user base. If you’re getting an AI assistant for your SOAP documents, you’ll need it to be friendly and easy to use because doctors are trained in medicine and patient support, not computers. The simpler the AI is, the better most doctors will be able to use it, and this will result in wider adoption and even more efficiency.

Data privacy

Data privacy is something that you’ll need to ensure if you’re working with an AI. Some malicious companies mine the user data gathered by their technology, while others don’t have good security to protect against hackers. In the medical field, any and all patient information is highly confidential and is not for public use, so protecting this information using firewalls, VPNs, and hard backups is crucial. This will also help you avoid getting into trouble with regulators.

AI training and validation

AI can be used for virtually any task, but these tasks are wide-ranging and often need complex steps and instructions. Before you’re ready to use AI to generate SOAP documents, you’ll need to train it and give it the proper format, especially if your hospital uses a different format than usual. In simpler terms, this means letting the AI system see many different types of medical situations and professional SOAP note examples while it’s learning. If you’re getting a specially made AI assistant, you should still try it out and test it to validate its functionality to avoid creating inaccurate SOAP documents.


Customization is important for any AI assistant. There may be dozens or hundreds of doctors in your hospital, and all of them have their unique methods of approaching the task of creating a SOAP note. For these cases, it’s important for an AI to be customizable and adapt to different users and use cases. This will allow the AI to efficiently work and generate documents no matter which doctor or technician handles it.

Continuous training and support

Giving your AI continuous training is crucial. In the field of medicine, things are never still, as researchers and developers around the world are busy creating new medicines, machines, and technology and trying to combat new diseases. There will inevitably be a change in the standard methods of note-taking, and to ensure your AI does not become obsolete, it will need continuous training and support in the form of software updates.


If you’re using an AI to generate your notes, you’ll need to ensure that the system can operate and connect to the rest of the databases found in your hospital’s records. This includes telemedicine platforms, electronic records, and diagnostic tools. Without access to these records, the SOAP note won’t be as accurate or helpful, and with access to all of these files and documents, your AI will be able to find everything it needs efficiently.


It’s important to be transparent with the doctors who will be using any AI assistant to help with their work. The most advanced AIs are able to use lab values and blood tests to generate a hypothesis or even a diagnosis, but it’s important for doctors to know that this is a helpful tool rather than an actual decision. The doctors will still be in control, and it’ll be their choice how much they want to rely on the assistant.


Auditing is the simple practice of taking a few hours a month and double-checking the notes and documents that the AI is generating. Since AIs can generate so many documents each month, checking them all would be impossible, so hospitals opt to randomly select a few documents and SOAP notes, reading them to ensure that the AI hasn’t been making any mistakes. This reduces the risk of long-term problems and ensures that the records used will remain usable for years to come.


AI has been getting more and more popular all over the world. It’s been integrated into many activities already, but one of the greatest impacts it’s had so far is in the field of medicine, where doctors have been able to use it to create SOAP notes and documents. It allows fast turnover of patients, resulting in more people being able to see the doctor and a higher efficiency of work at a low added cost.