SOAP note example: knee osteoarthritis
Knee osteoarthritis notes should say how the knee limits the patient's life, what the exam found, and what core treatment was offered, because that is what later decisions on injections, imaging or surgical referral depend on. The invented notes here show a typical visit and a flare with effusion, followed by a guide to each SOAP section.
Example: knee osteoarthritis visit
S: 63-year-old woman, 2 years of right knee pain, worse over 6 months. Pain on stairs and after walking 20 minutes; stiffness in the morning under 15 minutes. Occasional clicking, no locking or giving way. Left knee mildly painful. No night pain at rest, no fever, no hot swollen joint, no trauma. Paracetamol with little effect. Walks her dog daily, has stopped her exercise class. Goal: to walk 45 minutes again. No stomach ulcer, kidney disease or heart failure. O: BMI 31. Antalgic gait on the right. Right knee: bony enlargement, crepitus, no effusion, no warmth. Medial joint line tenderness. Flexion 110 degrees, full extension. Ligaments stable. Hip examination normal both sides. Left knee: crepitus, full range. A: Osteoarthritis, right knee greater than left, clinical diagnosis. Moderate functional limitation. P: 1. Explained osteoarthritis and that activity helps rather than harms the joint. 2. Physiotherapy referral for strengthening program. 3. Weight loss support; target 5% weight reduction. 4. Topical diclofenac gel up to 3 times daily to right knee. 5. X-ray not needed for diagnosis at present. 6. Review in 3 months to measure walking distance against her goal. 7. Return sooner for a hot, swollen knee, fever or inability to bear weight.
Content of each SOAP section for knee osteoarthritis
- S carries duration, pain pattern with activity, morning stiffness length, mechanical symptoms (locking, giving way), function in concrete terms such as walking distance or stairs, sleep, the patient's goal, treatments tried with their effect, and comorbidities that limit medicine choices. The red flags (hot swollen joint, fever, trauma, rest and night pain) belong here as answered questions.
- O carries gait, BMI, inspection, effusion, warmth, crepitus, joint line tenderness, range of movement in degrees, ligament stability, and an examination of the hip, since hip disease can refer to the knee.
- A states the joint and side, how the diagnosis was made (clinical or with imaging), and functional impact.
- P covers education, exercise or physiotherapy, weight management, analgesia with the safety checks, aids, imaging only if needed, and review against a function goal.
A function goal written in the first note, like the walking distance above, gives every later visit something to measure.
Example: flare with effusion
S: 70-year-old man with known left knee osteoarthritis. 1 week of more pain and swelling after gardening. No fever, no redness, able to bear weight. No previous gout. O: Temp 36.7. Left knee: moderate effusion, mildly warm, not red. Flexion 90 degrees. Walks with a limp. A: Flare of left knee osteoarthritis with effusion. No features suggesting infection or crystal arthritis at present. P: Relative rest for a few days, ice, topical anti-inflammatory. Review in 1 week; consider aspiration if not settling. Same-day return for fever, redness or inability to bear weight.
Gaps seen in knee osteoarthritis notes
- Function described as "limited" rather than with a distance, time or task.
- No hip examination documented.
- Range of movement given without degrees.
- Core treatment (exercise, weight) not documented as offered before injections or surgery are discussed.
- Infection and crystal arthritis not addressed in a swollen, warm knee.
ICD-10 codes for knee osteoarthritis
| Code | Meaning |
|---|---|
| M17.11 | Unilateral primary osteoarthritis, right knee (ICD-10-CM) |
| M17.12 | Unilateral primary osteoarthritis, left knee (ICD-10-CM) |
| M17.0 | Bilateral primary osteoarthritis of knee |
| M17.9 | Osteoarthritis of knee, unspecified |
| M25.561 / M25.562 | Pain in right knee / left knee, before a diagnosis is made |
The laterality digits are ICD-10-CM. Base ICD-10 uses the M17 category (gonarthrosis) at four characters.
ClearPass for musculoskeletal visits
In a knee visit you examine and talk at the same time. Transcribe (the patient agrees first) keeps both, and ClearPass writes the SOAP draft with the function history in S and the findings you called out, such as degrees of flexion or joint line tenderness, in O. Detailed keeps every finding; Concise suits a quick review.
Degrees, BMI and doses that were not in the transcript are marked by the numbers check. The M17 code is one click, and so are patient instructions on exercise and pain relief and a physiotherapy or orthopedic referral letter. Review and correct the draft 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
Does a knee osteoarthritis SOAP note need an X-ray result?
Not always. In older adults with typical symptoms, the diagnosis is often clinical. If imaging was not done, say it was not needed and why.
How should function be documented?
With measurable examples such as walking distance, stairs, or tasks the patient cannot do, plus a stated goal.
Can ClearPass write an orthopedic referral from the visit?
Yes. A referral letter is one click from the visit, written from what was said. You review it before sending.
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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