Using Generative AI to Improve Clinical SOAP Note Writing

School of Pharmacy

About this use case

Students review and interpret clinical documents, identify relevant subjective and objective information from a patient case, and write a SOAP note addressing the management of the patient’s condition. The assessment includes an original SOAP note and a mandatory generative AI-supported revision. Students submit a tracked-changes version of the improved note and explain how their revisions strengthen its effectiveness.

Learning outcomes:

Demonstrate effective clinical documentation.
Integrate generative AI responsibly into SOAP note writing with appropriate acknowledgement of its use.

To help students
- demonstrate their ability to interpret clinical information,
- document patient care effectively and
- use generative AI responsibly to reflect on and improve their clinical writing.
1. Provide students with the patient problem, recommendations and relevant progress or admission notes.
2. Guide students in identifying subjective and objective information from the patient case.
3. Introduce the structure and purpose of SOAP notes.
4. Provide directed prompts that help students reflect on and improve their original SOAP note.
5. Explain how to use tracked changes and comments to document revisions.
6. Require students to acknowledge and document their use of generative AI.
7. Reinforce that personal identifiers and confidential information must not be included in AI prompts or outputs.
8. Direct students to LearnHQ and Monash University guidance on responsible AI use and academic integrity.
- Improved clinical documentation skills.
- Greater ability to interpret clinical records in the context of patient management.
- Stronger identification of relevant subjective and objective information.
- Improved ability to evaluate and revise a SOAP note.
- Greater transparency in documenting AI-assisted revisions.
  Increased awareness of confidentiality, ethical AI use and academic integrity.

Try it out

This use case requires a medium level of effort to implement.

- Ask students to prepare an original clinical document, such as a SOAP note, using information from a patient case.
- In a subsequent task, require them to use a generative AI tool with directed prompts to review and improve their original work.
- Require a tracked-changes version showing all revisions and comments explaining how each change improves the document.
- Provide clear instructions for acknowledging AI use, protecting confidential information and maintaining academic integrity.
- Clearly separate the original student-authored work from the AI-supported revision.
- Make the use of generative AI mandatory only where specified and require students to show how they evaluated and modified the AI-supported changes.
- Students should document the tool, prompts, outputs, revisions and number of iterations.
- Reinforce that submitted work must remain a genuine demonstration of the student’s own clinical knowledge, judgement and skills.
- Ensure sufficient marking capacity is available, as reviewing students’ initial and revised SOAP notes, tracked changes and comments can involve a substantial marking workload.
Seeing a developmental arc through sampling over time
Visible learning is implemented through a development arc, where students submit an initial SOAP note, use directed prompts to reflect on and revise their work, and document changes using tracked changes and comments. This allows the assessment to capture not only the final product, but also students’ reasoning, reflection, and development.

Supporting resources

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Sidebar

Unit: PHR2011	Condition: Individual
Class size: 120–125	Typology: Written
AI approach: Using and applying AI tools effectively	AI statement: Guided use
Visibility of Learning: Seeing a developmental arc through sampling over time

About the educator

Validated by

Shannon Ng, Education Designer, Education Excellence