SOAP note example: hypothyroidism
Hypothyroidism is managed by numbers over months: TSH, free T4, the levothyroxine dose and the timing of the next test. A note that gives the result without the reference range, or the dose change without the reason, makes the next adjustment harder. The invented notes below show a diagnosis visit and a dose review, then the content of each section.
Example: new primary hypothyroidism
S: 47-year-old woman, 4 months of tiredness, feeling cold, constipation and dry skin. Weight up 3 kg. Periods regular, not pregnant, not planning pregnancy. No neck swelling or pain, no swallowing difficulty. No chest pain or palpitations. No previous thyroid surgery or radioiodine. Not on amiodarone or lithium. Mother has hypothyroidism. O: Pulse 62, regular. BP 124/78. Weight 71 kg. Dry skin. No goitre or nodules on palpation. Reflexes normal. Bloods: TSH 9.8 mU/L (ref 0.4 to 4.0), free T4 9 pmol/L (ref 12 to 22), repeat confirms. Thyroid peroxidase antibodies positive. Full blood count normal. A: Primary hypothyroidism, likely autoimmune thyroiditis. No cardiac disease. P: 1. Start levothyroxine 50 micrograms once daily. 2. Take on an empty stomach with water, 30 to 60 minutes before breakfast; separate from calcium and iron by 4 hours. 3. TSH in 6 to 8 weeks, then adjust dose. 4. Symptoms may take several weeks to improve. 5. Tell us early if pregnancy is planned or occurs, as the dose usually needs to rise. 6. Return for chest pain or palpitations after starting.
Section guide for a thyroid visit
The Subjective section lists symptoms with duration and change, pregnancy status and plans, previous thyroid surgery, radioiodine or neck radiotherapy, drugs that affect thyroid function or absorption (amiodarone, lithium, iron, calcium), family history, and at review, how and when the tablet is taken. Cardiac symptoms belong here too because they affect starting doses.
In Objective, write pulse and blood pressure, weight, neck examination (goitre, nodules), and the thyroid results with units, reference ranges and dates. Antibody results and any other relevant bloods follow.
Assessment gives the diagnosis with its type (primary, secondary, subclinical, postprocedural) and whether the patient is on target. The Plan holds the levothyroxine dose, the reason for any change, how to take it, the date of the next TSH, and special advice for pregnancy.
Example: dose adjustment
S: 8 weeks on levothyroxine 50 micrograms. Energy better, still cold at times. Takes it before breakfast, iron tablets at lunch. O: Pulse 68. TSH 4.9 mU/L (ref 0.4 to 4.0), free T4 13 pmol/L. A: Primary hypothyroidism, improving, TSH still above range. P: Increase levothyroxine to 75 micrograms once daily. Repeat TSH in 6 to 8 weeks. Continue separating from iron.
Frequent documentation gaps
- TSH written without units or reference range.
- Dose changed without writing the old dose, new dose and reason.
- Tablet timing and interacting supplements not asked.
- Pregnancy plans not documented in a woman of reproductive age.
- No date or interval for the next blood test.
ICD-10 codes for hypothyroidism
| Code | Meaning |
|---|---|
| E03.9 | Hypothyroidism, unspecified |
| E06.3 | Autoimmune thyroiditis |
| E89.0 | Postprocedural hypothyroidism (after surgery or radioiodine) |
| E03.2 | Hypothyroidism due to medicaments and other exogenous substances |
| E03.8 | Other specified hypothyroidism |
These codes exist in both base ICD-10 and ICD-10-CM. How subclinical hypothyroidism is coded varies; check your service's convention.
How ClearPass drafts a thyroid review
Thyroid reviews are brief and number-driven. During the visit, Transcribe (after the patient has agreed) takes the conversation; you can read the latest results aloud, or photograph the lab report and let photo upload read the values in, removing identifiers first. ClearPass then writes the SOAP note with results in O and the dose decision in P.
The numbers check matters here: a TSH or dose in the note that nobody said is marked for you to confirm. E03 and E06 codes are one click. Patient instructions on taking levothyroxine and the next blood test, or an endocrinology referral, are one click each. Treat the output as a draft to review.
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
Where do TSH results go in a SOAP note?
In Objective, with value, units, reference range and date. The interpretation, such as above target, goes in Assessment.
What should the plan say when changing levothyroxine?
The old and new dose, the reason, how to take it, and when TSH will be repeated.
Can ClearPass read a thyroid lab report from a photo?
Yes, photo upload reads clinical details from a photographed report into the note. Photos are not automatically redacted, so remove identifiers first, and check the values.
What does ClearPass cost?
The 7-day trial is free, needs no card and simply ends after 7 days, with no automatic charge. After that there is one plan: $78 a month or $858 a year, with every visit transcribed.
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