Executive Summary
This report is based off of a database of curated medical notes in SOAP format to identify which documentation items appear consistently across visits. The goal is to provide a scribe with a reliable checklist of items to capture at every appointment, plus items that should be captured in most situations regardless of chief complaint. This report is based off the findings within our database.
Priority Tiers
| Priority | Frequency | Meaning |
|---|
| Always Include | 85–100% | Found in virtually every note. Document at every visit without exception. |
| Usually Include | 65–84% | Found in most notes. Capture at most visits; omit only if clearly not applicable. |
| Often Include | 40–64% | Found in many notes. Document when relevant to the visit type or patient history. |
| Situational | <40% | Case-dependent. Document when relevant to the specific chief complaint or findings. |
Universal Items (85%+ of All Notes)
These items should be captured at every single visit, regardless of the reason for presentation.
| Section | Item | Frequency |
|---|
| Subjective | Vomiting / diarrhea status (present or denied) | 19/20 (95%) |
| Subjective | Current medications / supplements (or “none”) | 18/20 (90%) |
| Subjective | Diet details (brand, amount, frequency) | 18/20 (90%) |
| Subjective | Urination / drinking / bowel habits | 17/20 (85%) |
| Plan | Owner education / counseling documented | 19/20 (95%) |
SUBJECTIVE Section
The Subjective section captures the patient history as reported by the owner, including the chief complaint, systems review, and lifestyle information. This section is the most standardized across visits.
Frequency Overview
Vomiting / Diarrhea Status 19/20 Current Medications / Supplements 18/20 Urination / Drinking / Bowel Habits 17/20 Parasite Prevention Status 16/20 Mobility / Lameness Status 14/20 Relevant Medical History 13/20 Exercise / Activity Level 12/20 Coughing / Sneezing Status 11/20 Owner Concerns / Questions 8/20 Detailed Item Descriptions
Vomiting / Diarrhea Status Always Include
19/20 (95%)
Presence or absence of vomiting and/or diarrhea. Essentially a universal pertinent negative or positive, documented even when the chief complaint is unrelated.
Example phrases: - “Denies coughing, sneezing, vomiting, or diarrhea at home”
- “No vomiting or diarrhea reported”
- “Presents with unexplained diarrhea”
Current Medications / Supplements Always Include
18/20 (90%)
All current medications and supplements, including explicit documentation of “no medications” when none are being given.
Example phrases: - “No meds or supplements”
- “On Galliprant daily; owner reports clear benefit”
- “Currently receiving Fortiflora probiotic powder supplement”
Diet Details Always Include
18/20 (90%)
Brand, type, amount, and feeding frequency of the patient’s diet. Nearly always includes brand name and daily quantity.
Example phrases: - “Diet consists of H1 beef and barley, Stella’s breeds dried beef”
- “Currently receives 2/3 cup of senior Fromm dog food per day”
- “GO Skin & Coat food, 2 cups daily (1 cup AM, 1 cup PM)”
Urination / Drinking / Bowel Habits Always Include
17/20 (85%)
Normal vs. abnormal elimination patterns and hydration/water consumption status.
Example phrases: - “No issues with urination or bowel movements”
- “Normal water consumption and urination”
- “Patient drinks 2–3 liters of water daily, increased from normal”
Parasite Prevention Status Usually Include
16/20 (80%)
Current or past flea/tick and heartworm prevention products, dosing schedule, and last dose given.
Example phrases: - “On Nexgard”
- “On NexGard Spectra for parasite prevention, given monthly from April to November”
- “History of Bravecto for flea/tick; given every few months, not in winter”
Mobility / Lameness Status Usually Include
14/20 (70%)
Assessment of the patient’s ability to move, walk, climb stairs, etc. Includes both positive findings and explicit “no concerns.”
Example phrases: - “No mobility issues, very active”
- “Shows signs of mobility issues”
- “No mobility concerns noted”
Relevant Medical History Usually Include
13/20 (65%)
Prior diagnoses, surgeries, chronic conditions, and previous treatments that inform the current visit.
Example phrases: - “Has history of knee and back problems”
- “Grade 2 heart murmur in 2023”
- “History of cherry eye surgery on R eye good recovery”
Exercise / Activity Level Often Include
12/20 (60%)
Daily exercise routine, activity level, and energy assessment.
Example phrases: - “Exercise includes 2–3 kilometer walks”
- “Gets multiple daily walks”
- “Good energy, daily runs”
Treats / Extras Often Include
12/20 (60%)
Treats, chews, human food, or supplemental food items given outside of regular meals.
Example phrases: - “Patient receives dental sticks — two pieces daily”
- “Gets peanut butter occasionally as treats”
- “No human food except weekly milk portion”
Coughing / Sneezing Status Often Include
11/20 (55%)
Presence or absence of coughing or sneezing. Often documented alongside V/D as a systems review.
Example phrases: - “No current coughing or sneezing”
- “Exhibits coughing when pulling on leash”
- “Occasional sneezing bouts twice per month”
Vaccination History Often Include
9/20 (45%)
Current vaccination status, dates of last vaccines, and which are due.
Example phrases: - “Distemper vaccine is current until 2027”
- “Rabies & DHPP current through 2027”
- “Patient received vaccines in December”
Appetite Status Often Include
8/20 (40%)
Whether the patient is eating normally, more, or less than usual.
Example phrases: - “Good appetite”
- “Slight decrease in appetite reported”
- “Not eating since procedure”
Previous Weight Often Include
8/20 (40%)
Historical weight measurements for comparison to current visit.
Example phrases: - “Past weights range 4.1–4.8 kg”
- “Previous weight 13.8kg”
- “Weight was 6.6 kg a year ago, 7.1 kg in November”
Owner Concerns / Questions Often Include
8/20 (40%)
Specific concerns or questions raised by the owner beyond the chief complaint.
Example phrases: - “Owner worried about hearing and vision loss”
- “Owner concerned pt is underweight”
- “Owner inquires if the wound is progressing normally”
Scribe Checklist: Subjective
At every visit, the scribe should document these Subjective items:
- Chief complaint / reason for visit
- Vomiting and/or diarrhea: present or explicitly denied
- Current medications and supplements (or state “none”)
- Diet: brand, type, amount per day, feeding frequency
- Urination, drinking, and bowel movement status
- Parasite prevention: product, schedule, last dose
- Mobility / lameness status
- Coughing / sneezing status (if time permits or relevant)
- Exercise / activity level
- Relevant medical history (chronic conditions, prior surgeries)
- Treats or supplemental food items
- Appetite (especially if changed)
- Previous weight (for comparison)
- Owner concerns or questions beyond the chief complaint
OBJECTIVE Section
The Objective section records physical examination findings and any test results obtained during the visit. This section varies more with the nature of the visit but certain baseline findings are consistently recorded.
Frequency Overview
Cardiac Auscultation / Heart Rate 15/20 Dental / Oral Exam Findings 14/20 Respiratory / Lung Auscultation 14/20 Abdominal Palpation 12/20 Lymph Node Palpation 12/20 Eye Examination Findings 12/20 Ear Examination Findings 11/20 Body Condition Score (BCS) 8/20 Masses / Lumps / Skin Tags 8/20 Skin / Coat Findings 7/20 Musculoskeletal / Orthopedic Exam 7/20 Detailed Item Descriptions
Weight (Measured) Usually Include
16/20 (80%)
Current body weight recorded during the visit.
Example phrases: - “Weight: 4.8 kg”
- “weight 15.2kg”
- “Current weight is 5.6 kg”
Cardiac Auscultation / Heart Rate Usually Include
15/20 (75%)
Heart rate measurement and/or auscultation findings including presence or absence of murmurs, rhythm, and pulse quality.
Example phrases: - “HR 102”
- “Has a grade 2–3/6 heart murmur”
- “Heart auscultation normal; no murmurs or arrhythmias detected”
Dental / Oral Exam Findings Usually Include
14/20 (70%)
Findings on teeth, gums, and oral cavity including tartar, calculus, gingivitis, missing/fractured teeth, and halitosis.
Example phrases: - “Dental examination reveals calculus, gingivitis, and halitosis”
- “mild tartar on upper right molars”
- “Mild calculus present on caudal teeth”
Respiratory / Lung Auscultation Usually Include
14/20 (70%)
Lung sounds, respiratory rate, respiratory effort, and presence of panting.
Example phrases: - “Panting”
- “clear breath sounds”
- “Lungs clear on auscultation”
Abdominal Palpation Often Include
12/20 (60%)
Findings from abdominal palpation including tension, softness, masses, or pain.
Example phrases: - “Abdomen slightly tense”
- “Soft abdomen”
- “Normal abdomen on palpation”
Lymph Node Palpation Often Include
12/20 (60%)
Assessment of peripheral lymph nodes for size, symmetry, and abnormalities.
Example phrases: - “normal lymph nodes”
- “Both popliteal lymph nodes enlarged”
- “Peripheral LN’s normal”
Eye Examination Findings Often Include
12/20 (60%)
Findings on eyes including discharge, lens changes, tear production, corneal findings.
Example phrases: - “crusted eye discharge”
- “Lens clouding”
- “bright eyes”
Ear Examination Findings Often Include
11/20 (55%)
Findings on ear canals including wax, odor, inflammation, cleanliness.
Example phrases: - “Ears pink”
- “dark wax and slight yeasty odor in ears”
- “Ears clean”
Body Condition Score (BCS) Often Include
8/20 (40%)
Standardized body condition scoring, typically on a 1–9 scale.
Example phrases: - “BCS 7/9”
- “Body condition score 5.5–6 out of 9”
- “body condition score 4/9”
Masses / Lumps / Skin Tags Often Include
8/20 (40%)
Documentation of any palpable or visible masses with size and location.
Example phrases: - “Posterior back with fatty feeling lump”
- “3 cm raised, round, firm, hairless mass on right hip”
- “Small white bump/skin tag on neck”
Skin / Coat Findings Situational
7/20 (35%)
Skin condition, hair coat quality, lesions, erythema, or alopecia.
Example phrases: - “Has erythematous lesions on ventral abdomen”
- “Alopecia”
- “Hair coat mildly overgrown”
Musculoskeletal / Orthopedic Exam Situational
7/20 (35%)
Range of motion, joint palpation, lameness assessment, and muscle mass evaluation.
Example phrases: - “stiffer mobility on left side”
- “Mild bilateral patellar laxity”
- “Good muscle mass and full ROM in all joints”
Scribe Checklist: Objective
At every visit, the scribe should record these Objective findings:
- Weight (measured, in kg or lbs)
- Body condition score (BCS out of 9)
- Heart rate and cardiac auscultation (murmur yes/no, grade if present)
- Respiratory: lung sounds, respiratory rate/effort, note panting
- Dental / oral exam findings (tartar, gingivitis, fractured teeth, halitosis)
- Abdominal palpation (soft, tense, masses, pain)
- Lymph node palpation (normal/abnormal, which nodes)
- Eye examination findings (discharge, clarity, tear production)
- Ear examination findings (clean, wax, odor, inflammation)
- Any masses, lumps, or skin tags (size, location, character)
- Skin / coat condition (if abnormalities noted)
- Musculoskeletal findings (ROM, lameness, muscle mass — if relevant)
- Any diagnostic test results obtained during visit
- Any positive physical exam finding noted by the provider
ASSESSMENT Section
The Assessment section is the most case-dependent of all four SOAP sections. However, certain assessment categories recur frequently because they address common wellness findings that veterinarians evaluate regardless of the presenting complaint.
Frequency Overview
Weight / Body Condition Assessment 14/20 Dental Disease Assessment 13/20 Presenting Problem Diagnosis / DDx 11/20 Vaccination Status Assessment 11/20 Comparison to Previous Findings 7/20 Parasite Prevention Assessment 5/20 Detailed Item Descriptions
Weight / Body Condition Assessment Usually Include
14/20 (70%)
Interpretation of whether the patient is at, above, or below ideal weight, and comparison to previous visits.
Example phrases: - “moderately overweight”
- “Overweight, Weight increased 1.4kg”
- “Ideal weight”
- “At goal weight”
Dental Disease Assessment Usually Include
13/20 (65%)
Interpretation of dental findings and periodontal disease severity.
Example phrases: - “Moderate dental calculus/periodontal disease”
- “Early dental disease and chipped tooth”
- “Dental tartar and halitosis – candidate for routine dental prophylaxis”
Presenting Problem Diagnosis / DDx Often Include
11/20 (55%)
Primary diagnosis or differential diagnosis list for the chief complaint and secondary findings.
Example phrases: - “diarrhea — likely dietary intolerance”
- “Allergic dermatitis with secondary self-trauma”
- “Perianal dermatitis/irritation, likely from licking”
Vaccination Status Assessment Often Include
11/20 (55%)
Which vaccines are due, current, or coming due.
Example phrases: - “Due for rabies vaccine”
- “Due for distemper/parvo, rabies, and leptospirosis vaccines”
- “rabies and distemper due next year”
Comparison to Previous Findings Situational
7/20 (35%)
Explicit comparison of current findings to those from prior visits.
Example phrases: - “Heart murmur unchanged from last visit”
- “Multiple lipomas are stable in size”
- “Thigh lipoma is stable size”
Parasite Prevention Assessment Situational
5/20 (25%)
Assessment of whether parasite prevention is current, overdue, or adequate.
Example phrases: - “Due for parasite prevention”
- “off schedule for flea/tick”
- “no heartworm prevention”
Scribe Checklist: Assessment
The Assessment is inherently driven by findings, but scribes should watch for these recurring patterns:
- Weight / body condition judgment (overweight, ideal, underweight, weight trend)
- Dental disease severity and whether intervention is recommended
- Vaccination status: which vaccines are due, current, or coming due
- Primary diagnosis or differential diagnosis for the chief complaint
- Comparison to previous visit findings (masses stable? murmur unchanged?)
- Parasite prevention: is coverage adequate or overdue?
PLAN Section
The Plan section documents all actions taken, recommendations made, and follow-up arrangements. This section contains the most consistently documented items, as almost every visit concludes with owner education and follow-up instructions.
Frequency Overview
Owner Education / Counseling 19/20 Follow-Up / Recheck Timeline 16/20 Medications Prescribed / Dispensed 14/20 Monitoring Instructions 14/20 Vaccines Administered / Scheduled 13/20 Dental Treatment Recommended 11/20 Diagnostics Ordered / Recommended 11/20 Parasite Prevention Dispensed / Started 10/20 Weight / Diet Management Plan 9/20 Return / ER Precautions 7/20 Cost / Financial Discussion 7/20 Vaccine Reaction Counseling 6/20 Detailed Item Descriptions
Owner Education / Counseling Always Include
19/20 (95%)
Discussions with the owner about diagnosis, treatment options, home care, risks, prognosis, or preventive care.
Example phrases: - “owner educated on proper ear cleaning technique”
- “Discussed weight loss strategies”
- “Counseled on dental exam under anesthesia”
Follow-Up / Recheck Timeline Usually Include
16/20 (80%)
Scheduling or recommending specific follow-up appointments with timeframes.
Example phrases: - “Follow-up recheck scheduled for one month”
- “Recheck in 1–2 weeks or sooner if…”
- “Follow up on the 25th”
Medications Prescribed / Dispensed Usually Include
14/20 (70%)
Specific medications prescribed including drug name, dose, frequency, duration, and route.
Example phrases: - “Prescribed Surolan cream for lip fold infection – twice daily for 14 days”
- “Apoquel for itching once daily 14 days”
- “Onsior injection and 4 doses to go home”
Monitoring Instructions Usually Include
14/20 (70%)
Specific signs, symptoms, or parameters the owner should watch for at home.
Example phrases: - “Monitor eyelid mass for growth or irritation”
- “track water intake, appetite, stool consistency”
- “Monitor for further anal/defecation issues”
Vaccines Administered / Scheduled Usually Include
13/20 (65%)
Vaccines given at the visit or scheduled, including route and site.
Example phrases: - “Rabies vaccine given”
- “Leptospirosis booster — administered SC in the left hind leg”
- “Given FVRCP, Feline Leukemia, and Rabies vaccines today”
Dental Treatment Recommended Often Include
11/20 (55%)
Recommendations for dental cleaning, extractions, or COHAT procedures.
Example phrases: - “strongly recommend dental cleaning in near future”
- “dental cleaning recommended”
- “Schedule COHAT with anesthesia and dental radiographs”
Diagnostics Ordered / Recommended Often Include
11/20 (55%)
Bloodwork, imaging, cytology, or other diagnostic tests performed or recommended.
Example phrases: - “CBC and serum chemistry drawn today”
- “4DX blood test performed”
- “Discussed fine-needle aspiration cytology”
Parasite Prevention Dispensed / Started Often Include
10/20 (50%)
Dispensing or prescribing flea/tick and/or heartworm prevention products.
Example phrases: - “Nexgard Spectra dispensed for June dose”
- “start on Nexgard Spectra”
- “Continue NexGard monthly through November”
Weight / Diet Management Plan Often Include
9/20 (45%)
Target weight, calorie calculations, feeding recommendations, or diet changes.
Example phrases: - “Target weight set at 4.5 kg”
- “Calorie calculations to be sent to owner”
- “reduce caloric intake 10–15%, limit treats, increase exercise”
Return / ER Precautions Situational
7/20 (35%)
Explicit instructions for when the owner should return sooner or seek emergency care.
Example phrases: - “Return sooner for worsening diarrhea, hematochezia, vomiting, anorexia, collapse”
- “Return/call sooner for increased ocular discharge, corneal cloudiness”
- “Recheck sooner for appetite loss, swelling, or lump changes”
Cost / Financial Discussion Situational
7/20 (35%)
Discussions about procedure costs, wellness plans, or financial considerations.
Example phrases: - “Discussed dental procedure costs”
- “Discussed costs and wellness plan”
- “Discussed cost barriers of cyclosporine drops”
Vaccine Reaction Counseling Situational
6/20 (30%)
Post-vaccination monitoring instructions and expected vs. concerning side effects.
Example phrases: - “counseled on post vaccine soreness and possible side effects”
- “Monitor for vaccine reactions”
- “Routine monitoring for vaccine adverse effects”
Scribe Checklist: Plan
At every visit, the scribe should document these Plan items:
- Owner education / counseling: what was discussed (always document this)
- Follow-up / recheck: when and for what reason
- Medications prescribed: drug, dose, frequency, duration, route
- Monitoring instructions: what the owner should watch for at home
- Vaccines administered: which vaccines, route, injection site
- Dental recommendations: cleaning, extraction, or future scheduling
- Diagnostics ordered or recommended: bloodwork, imaging, cytology
- Parasite prevention: products dispensed, dosing schedule
- Weight / diet management: target weight, calorie plan, diet changes
- Return / ER precautions: specific warning signs to watch for
- Cost / financial discussions: documented for transparency
- Vaccine reaction counseling: post-vaccination monitoring advice
Methodology
This analysis was performed on 20 expert reviewed veterinary SOAP notes. Each transcript was read in full by the reviewer prior to note analysis. Frequency counts were determined through both manual review and automated text analysis, with discrepancies resolved by manual verification against the original notes.
The notes span a variety of visit types including wellness exams, vaccination visits, rechecks, dental pre-ops, dermatologic complaints, orthopedic concerns, post-surgical follow-ups, and oncology rechecks. This diversity strengthens the finding that high-frequency items truly are “visit-type-independent.”
Counts reflect how many of the 20 notes include each item category, not how many times it appears within a single note. Items were counted as present even when documented as a pertinent negative (e.g., “no vomiting” counts as documenting vomiting/diarrhea status).
Limitations
This analysis is based on 20 notes from a single practice/dataset. Patterns may differ across practices, specialties, or regions. The Assessment section showed the least consistency, which is expected since assessments are inherently case-driven. A larger sample size would improve confidence in the frequency estimates, particularly for items in the 40–60% range.
Citations