Key points
- A template is the instruction the scribe follows. The SOAP structure has guided clinical notes for almost 50 years and doubles as a checklist and a reasoning aid.1
- Follow-up notes should lead with change. In consecutive outpatient ophthalmology notes averaging 1,182 words, less than a quarter of the words changed between visits.2
- In 7,844 inpatient notes, 54% of discharge summaries duplicated text from earlier notes of the same type.3
- In 57 US physicians observed for 430 hours, 49.2% of the office day went on record and desk work.4
- wai shapes note and letter templates to the specialty and refines them as the clinician edits.5
Summary
Give an AI scribe a template for each kind of visit, a SOAP note for new problems, a change-first template for follow-ups and a fixed outline for procedures. The template tells the scribe where each fact belongs, and your edits teach it the house style until the drafts need almost no change.
Picture every note reading as your own and ready to sign minutes after the patient leaves. The scribe hears the whole consultation, and the template decides what it keeps and where it goes, so an hour on templates in the first week pays back in every clinic after.
See it in your clinicThirty minutes on your own patients and doctors.
Request a demoSee one consultation drafted three ways, as a SOAP note, a follow-up and a procedure note, in your specialty's wording, in fifteen minutes.
| Template | Section | What goes in it |
|---|---|---|
| SOAP note | Subjective | Presenting complaint in the patient's words, history of the complaint, relevant past history, medicines, allergies, ideas, concerns and expectations |
| SOAP note | Objective | Observations, examination findings including relevant negatives, results available at the visit |
| SOAP note | Assessment | Working diagnosis, differentials considered, risk and severity in the clinician's words |
| SOAP note | Plan | Investigations, treatment with dose and duration, referrals, advice given, safety-net and follow-up interval |
| Follow-up | Since last visit | What has changed, new symptoms, response to treatment, side effects, adherence |
| Follow-up | Results since last visit | New results with date, and how they compare with the last |
| Follow-up | Progress against plan | Each item from the last plan, done, not done or changed |
| Follow-up | Assessment and plan | Current status, changes to treatment, next review date |
| Procedure note | Indication and consent | Why the procedure was done, risks discussed, consent confirmed and how |
| Procedure note | Pre-procedure checks | Identity, site, allergies, anticoagulants, equipment, chaperone if present |
| Procedure note | Anaesthesia and technique | Agent, dose and site, steps performed, devices or products with batch numbers |
| Procedure note | Findings and specimens | What was found, samples taken and where they were sent |
| Procedure note | Complications and blood loss | Any complication or none, estimated blood loss where relevant |
| Procedure note | Aftercare and follow-up | Advice given, warning signs, who to contact, review date |
The template is the scribe's instruction
A scribe decides from the template what belongs where. A precise template puts the assessment and plan where the reader looks first and keeps the draft short.
In a time and motion study of 57 US physicians in four specialties, observed for 430 hours, 49.2% of the office day went on record and desk work and 27.0% on direct clinical face time.4 For every hour with patients, nearly two more went on the record and desk work.4
SOAP, and why it lasts
The subjective, objective, assessment and plan structure was developed by Larry Weed almost 50 years ago.1 A StatPearls review describes it as a checklist, a cognitive aid and an index for retrieving information from the record, as well as a framework for clinical reasoning.1
For a scribe, the four headings keep what the patient reported apart from what the clinician found and concluded. Each claim has a known place, so a reviewer can check the draft in a minute.
Follow-ups should lead with what changed
A study of consecutive outpatient ophthalmology notes found an average length of 1,182 words, with less than a quarter of the words changing between visits.2 The plan section changed most, and the assessment and plan together made up a small fraction of the note.2
In 7,844 notes from 50 inpatients at a US academic medical centre, 54% of discharge summaries, 53% of consults and 47% of history and physical notes duplicated text from earlier notes of the same type.3
A follow-up template opens with the interval history and what has changed, then results since last time, then progress against the previous plan. Unchanged background stays in the record and out of the note.
Procedure notes need fixed fields
A procedure note is read by people who were not in the room, including auditors. It needs the same fields in the same order every time, and the clinician fills the ones a microphone cannot hear, such as what was checked silently before starting.
The outlines in the table below are starting points to adapt in the first week. Specialties add their own fields, such as an injection site map in aesthetics or a refraction in ophthalmology.
How wai learns your templates
wai shapes note and letter templates to your specialty and refines them as you edit, until every draft sounds like you.5 The note is drafted during the consultation in your structure, and you review, edit and sign it.5
Letters come from the same consultation in the same voice, and the letter templates show the shapes that work. The guide to the referral letter covers what a receiving specialist reads first.
Where to start
Write three templates from the outlines below before the first clinic with a scribe. Use them for a week unchanged, and tally every edit you make to a draft by section.
At the end of the week, move every repeated edit into the template, removing headings you keep deleting and adding lines you keep typing. Then measure the time from the end of each visit to the signed note against the first day, and enjoy the evenings that come back.
Bring the template you use most and watch wai draft into it, with your edits shaping the next draft.
Frequently asked questions
Can an AI scribe write SOAP notes?
Yes. A SOAP template tells the scribe where each fact belongs, and the clinician reviews and signs the draft. wai drafts notes structured the way the clinician writes.5
Should every visit use a SOAP note?
SOAP suits a new problem best. A follow-up reads better when it leads with what changed, and a procedure needs fixed fields in a fixed order.
How long does it take to set up templates?
An hour for three templates is enough to start. The bigger gain comes from a week of editing drafts and moving every repeated edit into the template.
Will templates make notes longer?
They should make them shorter. Copied-forward text is common, with 54% of discharge summaries in one study duplicating earlier summaries.3 A change-first follow-up template keeps unchanged background out of the note.
Can templates be specific to my specialty?
Yes. wai shapes note and letter templates to the clinician's specialty and refines them as the clinician edits.5
Who is responsible for what the template leaves out?
The clinician who signs the note. A template guides the draft, and the review before signing is where anything missing is added.
Sources
- 1StatPearls Publishing, Podder, Lew and Ghassemzadeh, 2023SOAP Notes, StatPearlsRead 14 October 2026Read source
- 2AMIA Annual Symposium Proceedings, Huang and colleagues, 2018Clinical Documentation in Electronic Health Record Systems: Analysis of Similarity in Progress Notes from Consecutive Outpatient Ophthalmology EncountersRead 14 October 2026Read source
- 3International Journal of Medical Informatics, Wang and colleagues, 2023An evaluation of copy and paste events in electronic notes of patients with hospital acquired conditionsRead 14 October 2026Read source
- 4Annals of Internal Medicine, Sinsky and colleagues, 2016Allocation of Physician Time in Ambulatory Practice: A Time and Motion Study in 4 SpecialtiesRead 14 October 2026Read source
- 5wai, 2026wai for cliniciansRead 14 October 2026Read source
Notes that read as your own, ready to sign when the patient leaves.
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