Breast Exam SOAP Note Example

A strong breast exam SOAP note begins with a Subjective section detailing the chief complaint, such as a palpable lump or routine screening, and a history of breast health or family risk. The Objective section must be granular, documenting symmetry, skin changes (like dimpling or erythema), nipple discharge, and the specific characteristics of any masses—including size, consistency, mobility, and clock-face location. The Assessment should synthesize these findings into a differential diagnosis, while the Plan outlines the next steps, such as diagnostic imaging or biopsy.

Rather than manually typing these details from memory, Aduvera captures the encounter as it happens. The AI medical scribe identifies the clinical markers mentioned during the exam and places them into the correct SOAP segment. This removes the burden of recalling exact measurements or locations after the patient has left, allowing the clinician to simply review the transcript-backed draft and finalize the documentation.