カルテ入力SOAP-AI-powered medical documentation.

Introduction to カルテ入力SOAP

カルテ入力SOAP is a specialized AI tool designed to assist in the creation of medical records using the SOAP (Subjective, Objective, Assessment, Plan) format. This tool distinguishes between physician and patient statements during outpatient consultations, accurately capturing the patient's description in the 'Subjective' section, while organizing the physician's observations, assessment, and proposed treatment plan in the 'Objective,' 'Assessment,' and 'Plan' sections respectively. Its primary purpose is to produce concise, professional medical records that omit non-medical dialogue and unnecessary details, maintaining a clinical tone appropriate for documentation. For example, during a consultation, if a patient describes their symptoms, カルテ入力SOAP will record this information under 'Subjective.' The physician's observations, such as physical examination findings, will be noted under 'Objective.' The diagnosis would be placed in 'Assessment,' and the treatment plan or follow-up steps in 'Plan.' This structure ensures clarity and completeness in medical records.