SOAP note example: migraine

Headache notes live or die on the history. The diagnosis of migraine rests on the pattern described, and the reassurance rests on a written red flag screen and a normal examination. Below are an invented first visit and a prevention follow-up, then the details each SOAP section should carry for a headache presentation.

Example: episodic migraine without aura

S: 32-year-old woman, headaches since her teens, more frequent over the past year: 3 to 4 attacks a month, each lasting most of a day. One-sided throbbing pain, worse with activity, with nausea and light sensitivity. No visual or sensory symptoms before attacks. Triggers: poor sleep, missed meals, before periods. Takes ibuprofen 400 mg with partial relief; uses painkillers on about 5 days a month. No headache on waking, no change with posture or coughing, no new pattern, no fever, weight loss or neurological symptoms. No history of cancer or immunosuppression. On progestogen-only pill. Non-smoker. Headache diary kept for 2 months.
O: BP 116/72, pulse 70. Alert and oriented. Cranial nerves normal. Fundi: clear disc margins both eyes. Power, tone, reflexes and coordination normal in all limbs. Gait normal. No neck stiffness. No temporal or sinus tenderness.
A: Migraine without aura, episodic. No red flag features. No medication overuse.
P: 1. Sumatriptan 50 mg at onset, may repeat once after 2 hours; not more than 2 doses in 24 hours. Continue ibuprofen 400 mg with it if needed.
2. Limit acute medicines to under 10 days a month; medication overuse headache explained.
3. Regular sleep and meals; continue diary.
4. Review in 3 months, sooner if attacks increase.
5. Seek urgent care for sudden severe headache, weakness, speech change, fever with neck stiffness or confusion.

Section by section for a headache visit

1. S: the pattern. Onset and duration of the headache disorder, attack frequency per month and headache days per month, duration of attacks, site and character, associated features (nausea, light and sound sensitivity), aura with its description, triggers, and every acute medicine with the number of days used per month.
2. S: the negatives. Thunderclap onset, headache worse lying or on coughing, new headache after 50, progressive pattern, fever, systemic illness, neurological deficits, cancer or immunosuppression, pregnancy or postpartum. Written as asked and absent.
3. O: the exam. Blood pressure, fundoscopy, cranial nerves, limb neurology, gait, neck stiffness, and temporal artery tenderness in older patients.
4. A and P. The headache type with aura status and frequency, presence or absence of medication overuse, acute treatment with limits, prevention if started, contraceptive considerations if aura is present, lifestyle advice, review timing and emergency advice.

Example: prevention follow-up

S: 32-year-old woman, migraine without aura. Diary shows 7 attack days a month despite triptan use. Uses acute medicines on 8 days a month. No asthma. Not planning pregnancy.
O: BP 114/70, pulse 68. Neurological exam unchanged, normal.
A: Episodic migraine, frequency now high enough to justify prevention.
P: Propranolol 40 mg twice daily; side effects and tiredness discussed. Continue diary. Review in 8 weeks; trial at least 3 months before judging effect.

Where migraine notes are thin

• No count of headache days and acute medicine days per month.
• Aura not asked about, although it changes contraceptive and treatment choices.
• Red flags absent from the note even when they were asked.
• Fundoscopy not mentioned in a new or changing headache.
• Acute treatment given without a limit on use.

ICD-10 codes for migraine and headache

The G43 subcodes above are ICD-10-CM. Base ICD-10 stops at four characters, for example G43.0 for migraine without aura.

What ClearPass does with a headache consultation

A migraine history is long and conversational. Transcribe (with the patient's agreement) captures it, and ClearPass arranges it into SOAP with the attack pattern, triggers and the red flag answers in S and the examination in O. Detailed mode is useful for a first headache visit; Concise suits a routine review.

Attack counts, medication days and doses are exactly the numbers that drift, so the numbers check marks any that were not in the transcript. The G43 code is one click. Patient instructions on acute medicine limits and warning symptoms, or a referral letter to neurology, take one click each. You read 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

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