SOAP note example: abdominal pain
Abdominal pain has a long list of causes, and a good note shows how that list was narrowed. The site, timing, associated symptoms, examination and pregnancy status all have to be written down, along with what the patient should do if the pain changes. The invented examples below illustrate structure only and are not clinical guidance.
Example: episodic right upper abdominal pain
S: 42-year-old woman, 3 episodes over 6 weeks of right upper abdominal pain starting 30 to 60 minutes after fatty meals, lasting 2 to 3 hours, radiating to the right shoulder blade. Nausea with episodes, no vomiting. Pain-free today. No fever, jaundice, dark urine, pale stools or itch. Bowels normal, no blood. No weight loss. No urinary symptoms. Last menstrual period 10 days ago, regular. No NSAID use. Alcohol rarely. O: Comfortable. Temp 36.7, pulse 74, BP 122/76. Not jaundiced. Abdomen soft, mild right upper quadrant tenderness, Murphy's sign negative, no guarding, no masses, no hepatomegaly. Bowel sounds normal. Urine dipstick normal. Urine pregnancy test negative. A: Episodic right upper quadrant pain, likely biliary colic. No features of cholecystitis, cholangitis or pancreatitis today. P: 1. Abdominal ultrasound. 2. Bloods: liver function tests, full blood count, amylase or lipase. 3. Low-fat diet while awaiting ultrasound. Paracetamol for pain. 4. Same-day care for pain lasting more than 6 hours, fever, yellow skin or eyes, dark urine or persistent vomiting. 5. Review with results; surgical referral if gallstones confirmed.
Section by section for abdominal pain
- S: characterize the pain. Onset (sudden or gradual), site at onset and now, radiation, character, severity, duration and pattern, relation to meals, bowels and movement.
- S: associated symptoms and context. Nausea, vomiting (and blood in it), bowel change, blood or black stools, urinary symptoms, fever, jaundice, weight loss. For anyone who could be pregnant: last menstrual period, contraception, vaginal bleeding or discharge. Medicines such as NSAIDs, alcohol, previous abdominal surgery.
- O: observations and exam. Full observations, general appearance, jaundice, abdominal inspection, site of tenderness, guarding, rebound or percussion tenderness, masses, organs, hernial orifices, bowel sounds, and pregnancy test and urine dipstick results.
- A: the differential. The working diagnosis and the serious alternatives considered for that site, with a word on why each is more or less likely.
- P: tests and safety. Investigations, treatment, referral with urgency, and specific return advice.
Example: acute right lower quadrant pain
S: 19-year-old woman, 14 hours of pain, started around the navel, now right lower abdomen. Nausea, off food. No diarrhea, no urinary symptoms. Last period 3 weeks ago, no vaginal bleeding. O: Temp 37.9, pulse 102, BP 118/72. Walks bent forward. Tender right iliac fossa with guarding, pain on coughing. Urine pregnancy test negative. Dipstick normal. A: Right lower quadrant pain, appendicitis suspected. Ovarian and other gynecological causes also considered. P: Same-day referral to the surgical team for assessment. Nothing to eat until assessed. Referral letter given.
What abdominal pain notes often miss
- Pregnancy status not documented in a patient who could be pregnant.
- Site of pain at onset not distinguished from site now.
- Guarding and peritoneal signs not mentioned either way.
- No observations, so a developing tachycardia or fever goes unseen.
- Return advice missing or vague when the patient is sent home.
ICD-10 codes for abdominal pain
| Code | Meaning |
|---|---|
| R10.11 | Right upper quadrant pain (ICD-10-CM) |
| R10.13 | Epigastric pain (ICD-10-CM) |
| R10.31 | Right lower quadrant pain (ICD-10-CM) |
| R10.84 | Generalized abdominal pain (ICD-10-CM) |
| R10.9 | Unspecified abdominal pain |
| K80 (category) | Cholelithiasis, once gallstones are confirmed |
Base ICD-10 groups these into R10.0 to R10.4 without quadrant digits. Use the most specific site you documented.
ClearPass for abdominal pain visits
An abdominal pain history is a long run of focused questions. Transcribe, started once the patient has agreed, captures them, and ClearPass lays out the SOAP draft with onset, site, associated symptoms and pregnancy status in S, and the examination you describe in O. Detailed mode keeps every negative, which is usually what you want for this presentation.
The draft reflects what was said; it does not decide urgency or diagnosis. Observations or test values in the note that were not in the transcript are marked by the numbers check. R10 codes are one click, and so are patient instructions with return advice and a referral letter for surgical or gynecological review. Check the draft before it goes into the chart.
What ClearPass does not do
- It does not replace your judgement. Every note is an AI draft that you review and correct before it is used.
- It is not a medical device and does not make clinical decisions. It is a documentation aid.
- It does not connect to your EMR. The note is copy-ready text that pastes into any system.
Privacy
Clinical note content is not stored on ClearPass servers: it is processed to write the note, then discarded. Consultation audio is transcribed and discarded, never stored. Your note history stays in your browser, on your device, and you choose how long it is kept. Common identifiers are removed from typed and transcribed text before it reaches the AI; that is a best-effort safeguard, so leave names, ID numbers and file numbers out where you can. Processing goes through the AI providers named in our Privacy Policy, which sets out exactly what each one receives and how long it keeps it. ClearPass does not sign HIPAA business associate agreements today.
Questions
Why document a pregnancy test in an abdominal pain note?
Pregnancy, including ectopic pregnancy, changes the differential and the management, so pregnancy status or the test result should be written for anyone who could be pregnant.
Should the note list diagnoses I ruled out?
Yes. Naming the serious alternatives considered, and why they seem less likely, shows the reasoning. The example is illustrative, not clinical guidance.
Does ClearPass mark exam values I did not say?
The numbers check marks numbers in the note that were not said in the transcript, such as a temperature or pulse, so you can confirm them.
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