# Clinical Documentation Prompts

# SOAP note scaffold
Subjective:
- Prompt: "Summarize the patient's presenting complaint in 2-3 sentences, including onset, severity, and context."

Objective:
- Prompt: "List vital signs, physical exam findings, and relevant lab/imaging results succinctly."

Assessment:
- Prompt: "Provide a concise assessment of the top differential diagnoses and the most likely diagnosis with justification."

Plan:
- Prompt: "Outline the immediate management steps, recommended tests, and follow-up plan. Include patient instructions for home care."

# Discharge summary
- Prompt: "Draft a discharge summary that includes reason for admission, hospital course, medications on discharge, follow-up appointments, and warning signs prompting return." 

# Referral letter
- Prompt: "Create a referral letter to [specialty] with a 3-sentence history, relevant findings, and a clear question for the consultant."

# ICD-10 suggestion
- Prompt: "Given the assessment, suggest ICD-10 codes and a short justification for each selected code."

# Safety checklist
- Prompt: "Before using any AI-generated clinical text, verify facts against the chart, ensure the clinician approves, and document the clinician's name and timestamp in the chart."