SOAP note example: gastroesophageal reflux disease

Reflux is a clinical diagnosis in most patients, so the note carries the weight: typical symptoms, the alarm features that were excluded, and what was tried. Without the alarm feature line, a later reader cannot tell whether endoscopy was considered. These invented notes show a first visit and a treatment review, with a guide to each section below.

Example: new reflux symptoms

S: 45-year-old man, 2 months of burning behind the breastbone after meals and lying down, 3 to 4 times a week. Sour taste in the mouth at night. Antacids help briefly. No difficulty or pain swallowing, no vomiting, no black stools or vomiting blood, no unintentional weight loss, no early fullness. No chest pain on exertion or breathlessness. Coffee 4 cups a day, late evening meals. Alcohol 10 units a week. Non-smoker. Occasional ibuprofen for knee pain. No family history of upper GI cancer.
O: BMI 29.2. BP 128/80. Abdomen soft, mild epigastric tenderness, no mass, no organomegaly. No pallor.
A: Gastroesophageal reflux disease, typical symptoms. No alarm features.
P: 1. Omeprazole 20 mg once daily, 30 to 60 minutes before breakfast, for 8 weeks.
2. Avoid ibuprofen; paracetamol for knee pain.
3. Smaller evening meals, 3 hours between eating and lying down, raise head of bed, reduce coffee and alcohol, weight loss advice.
4. Review at 8 weeks to step down to lowest effective dose.
5. Return sooner for swallowing difficulty, vomiting, black stools, weight loss or chest pain with exertion.

What to capture for reflux in S, O, A and P

1. Subjective. Heartburn and regurgitation with frequency per week, relation to meals, posture and night, response to antacids or previous acid suppression, and cough, hoarseness or throat symptoms. The alarm features asked and answered: dysphagia, odynophagia, persistent vomiting, bleeding, weight loss, anemia symptoms, and new onset in older patients. Medicines that aggravate reflux or injure the mucosa (NSAIDs, aspirin, bisphosphonates), alcohol, smoking, caffeine and meal timing.
2. Objective. Weight or BMI, abdominal examination including epigastric tenderness and masses, pallor, and blood results such as hemoglobin if taken.
3. Assessment. Reflux as typical or atypical, with or without alarm features, and response to prior treatment. Where chest pain is part of the story, a line on the cardiac question helps.
4. Plan. Acid suppression with dose, timing and duration, the step-down plan, lifestyle advice given, medicine changes, testing (for example Helicobacter pylori testing for dyspepsia or endoscopy referral with the reason), and return advice.

Example: eight-week review

S: Heartburn now once a fortnight on omeprazole 20 mg. Evening meals earlier, coffee down to 2 cups. No alarm symptoms.
O: Weight 88 kg, down 2 kg.
A: GERD, well controlled on acid suppression and lifestyle change.
P: Reduce to omeprazole 20 mg as needed on symptomatic days. Continue lifestyle changes. Return if symptoms return most days, or with any alarm symptom.

Documentation gaps in reflux visits

• Alarm features not written, even when they were asked.
• Acid suppression started with no duration or review, which leads to indefinite use.
• No note of NSAID or aspirin use.
• Chest pain in the history without any mention of the cardiac question.
• Timing instructions for the medicine not written in the plan.

ICD-10 codes for GERD

Esophagitis is usually confirmed at endoscopy; until then, K21.9 is the usual choice. Base ICD-10 uses K21.0 without the bleeding digit.

Reflux notes with ClearPass

Reflux visits are mostly history, and much of that history is negatives. Transcribe (the patient agrees first) captures the questions you asked about swallowing, bleeding and weight, and ClearPass puts them in S of the SOAP draft, so the alarm feature line exists without extra typing. Choose Concise for routine reviews.

Doses, weights and symptom frequencies that were not said are marked by the numbers check. K21.9 or another code is one click. Patient instructions on meal timing, how to take the tablet and warning symptoms are a second click, and a gastroenterology referral letter is a third. Read the draft and correct it before it is used.

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

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