Mastering the OLDCARTS SOAP Note with AI
Generate structured, high-fidelity clinical documentation that captures the nuance of patient symptoms. Our AI scribe helps you transform patient dialogue into accurate, EHR-ready SOAP notes.
HIPAA
Compliant
Clinical Fidelity in Every Note
Built for clinicians who prioritize accuracy and structured documentation.
Structured OLDCARTS Integration
Our AI automatically maps patient history to the OLDCARTS framework, ensuring that Onset, Location, Duration, Character, Aggravating/Alleviating factors, Radiation, Timing, and Severity are clearly documented.
Transcript-Backed Citations
Review every claim in your note against the original transcript. Per-segment citations allow you to verify the accuracy of the symptom history before finalizing your documentation.
EHR-Ready Output
Produce clean, professional SOAP notes that are formatted for seamless integration into your existing EHR system via simple copy-and-paste workflows.
From Encounter to Final Note
Follow these steps to generate a precise OLDCARTS-compliant SOAP note.
Record the Encounter
Capture the patient interaction within the web app, allowing the AI to process the dialogue into a structured clinical context.
Draft the OLDCARTS History
The AI generates a draft note, specifically organizing the History of Present Illness (HPI) using the OLDCARTS mnemonic to ensure no diagnostic detail is missed.
Review and Finalize
Verify the note against the transcript-backed citations to ensure clinical accuracy, then copy the finalized text directly into your EHR.
The Importance of Structured Symptom Documentation
The OLDCARTS mnemonic is a cornerstone of clinical practice, providing a systematic approach to the History of Present Illness. By ensuring each component—Onset, Location, Duration, Character, Aggravating/Alleviating factors, Radiation, Timing, and Severity—is addressed, clinicians can build a more robust diagnostic foundation. However, manually synthesizing this information into a SOAP note can be time-consuming and prone to omission, especially in complex cases.
Using an AI documentation assistant allows clinicians to maintain the rigor of the OLDCARTS framework while reducing the administrative burden. By leveraging transcript-backed source context, clinicians can ensure that the subjective data in their SOAP notes remains faithful to the patient's actual report. This structured approach not only improves the clarity of the HPI but also supports more efficient clinical review and assessment.
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Frequently Asked Questions
Transcript-backed documentation, clinician review, and EHR-ready note output are built into every workflow.
How does the AI ensure the OLDCARTS structure is followed?
The AI is designed to identify and categorize specific patient statements into the relevant OLDCARTS fields within the HPI section of the SOAP note, ensuring a comprehensive history.
Can I edit the note after the AI generates it?
Yes. The AI provides a draft for your review, and you retain full control to edit, verify, or adjust any section of the note to ensure it meets your clinical standards before finalizing.
How do I verify the accuracy of the symptoms reported?
You can use the transcript-backed source context and per-segment citations provided in the app to cross-reference the generated note against the original patient encounter.
Is this tool HIPAA compliant?
Yes, the platform is designed to be HIPAA compliant, ensuring that your clinical documentation workflow meets necessary privacy and security standards.
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