Are there apps that can help healthcare professionals write SOAP (Subjective, Objective, Assessment, and Plan) notes including anatomy and physiology (A&P) using medical guidelines and best practices?

SOAP Note Writing Apps and Clinical Documentation Tools

While there are apps and digital tools that can assist with SOAP note documentation, none currently provide comprehensive, guideline-based Assessment and Plan (A&P) generation that meets evidence-based clinical standards—you should be cautious about relying on any app for clinical decision-making in your A&P sections.

Current State of Clinical Documentation Apps

Limited Evidence-Based Content

• Most health apps, including those for clinical documentation, have not been assessed in clinical trials and are not evidence-based 1
• Many health apps recommend procedures that are not supported by evidence and do not adhere to evidence-based clinical guidelines 1
• Apps often rank "poor-acceptable" in information quality despite having acceptable functionality and aesthetics 1

Safety and Accuracy Concerns

• Health apps that function poorly pose serious threats to patient safety through incorrect recommendations 1
• In the absence of regulation, responsibility for adverse consequences from using these apps falls on the individual clinician 1
• There are substantial gaps in compliance with data protection principles regarding collection, storage, and transmission of personal information in many clinical apps 1

What Apps Can Realistically Help With

Documentation Structure and Format

• Apps can help with standardizing SOAP note format and structure 2, 3
• Automated SOAP classifiers can categorize clinical narrative sentences into appropriate SOAP sections with F1 scores of 93.9% (subjective), 94.5% (objective), 75.7% (assessment), and 77.0% (plan) 3
• Interactive teaching modules have demonstrated improved ability to write clinically appropriate SOAP notes 4

Communication and Data Entry

• HIPAA-compliant platforms like Doximity are recommended for secure physician communication 5
• Telemedicine platforms integrated with EHR systems (like Zoom with EPIC) enable efficient remote documentation 5
• Apps can facilitate symptom tracking and monitoring, though this is primarily for data collection rather than clinical interpretation 1

Critical Limitations for A&P Generation

Lack of Clinical Guideline Integration

• No comprehensive reviews exist demonstrating apps that provide in-depth, guideline-adherent clinical assessments 1
• The trustworthiness and adherence to evidence-based guidelines of app-provided clinical information remains unclear 1
• Apps struggle to account for specific patient characteristics such as treatment preference, access to care, age, and treatment history that are essential for individualized A&P 1

Regulatory Gaps

• Current regulatory standards do not provide appropriate guidance for health organizations to establish frameworks for managing clinical risks associated with clinical decision-support apps 1
• Only 14 commercially available diabetes apps (out of hundreds) had clinical outcomes data published or FDA clearance, and methodological issues were common 1

Practical Recommendations

Use Apps for Structure, Not Clinical Decisions

• Leverage apps for SOAP note formatting and organization, but generate your A&P based on your clinical judgment and current guidelines 2, 3
• Consider apps as documentation aids rather than clinical decision-support tools 1

Maintain Professional Standards

• Protect patient confidentiality and demonstrate respect in all digital interactions 5
• Ensure any mobile devices have secure remote access to hospital systems and HIPAA-compliant communication capabilities 5

Common Pitfalls to Avoid

• Never rely solely on app-generated clinical recommendations without verifying against current evidence-based guidelines 1
• Be aware that app developers' privacy disclosures may not be trustworthy, with many apps sharing data with third parties without proper disclosure 1
• Recognize that simply having a device or application does not change outcomes unless you actively engage with it to create positive health benefits 1