SOAP note example: type 2 diabetes
A diabetes review covers glucose control, kidneys, eyes, feet, cardiovascular risk and medicines in fifteen minutes. Notes that miss one of these leave the next clinician unsure whether it was checked. This page gives a full invented review note, a new-diagnosis note, and a checklist of what each SOAP section should carry for type 2 diabetes.
Example: routine diabetes review
S: 58-year-old woman, type 2 diabetes for 6 years, on metformin 1 g twice daily. Takes it regularly, mild loose stools settled. No hypoglycemia symptoms. Thirst and nocturia twice a night for 2 months. No chest pain or claudication. No numbness or tingling in the feet. Last eye screening 14 months ago. Non-smoker. Walks 20 minutes most days. O: Weight 84 kg, BMI 32.1 (was 83 kg). BP 134/82. HbA1c 67 mmol/mol (8.3%), previously 58 mmol/mol (7.5%). eGFR 78, urine albumin-to-creatinine ratio 2.1 mg/mmol. LDL cholesterol 2.4 mmol/L on atorvastatin 20 mg. Feet: skin intact, no callus, pedal pulses present, monofilament sensation normal at all sites tested both feet. A: Type 2 diabetes with worsening glycemic control, above her individual target of 53 mmol/mol (7.0%). No microvascular complications found today; eye screening overdue. Low foot risk. P: 1. Add empagliflozin 10 mg once daily. Genital hygiene, hydration and sick-day rules explained: pause during vomiting, dehydration or acute illness. 2. Continue metformin 1 g twice daily and atorvastatin 20 mg. 3. Eye screening referral today. 4. Dietitian referral for carbohydrate and weight advice. 5. HbA1c, eGFR and urine ratio in 3 months. 6. Seek care for vomiting, abdominal pain, breathlessness or marked drowsiness.
What belongs in each part of a diabetes note
S should capture how the patient takes their medicines, hypoglycemia episodes and what triggered them, osmotic symptoms, weight trend, diet and activity, smoking, and symptoms of complications: chest pain, claudication, foot numbness or burning, visual change, erectile dysfunction where relevant. Home glucose values, if the patient checks them, belong here with the pattern rather than a single reading.
O carries the measured values with their previous values beside them: HbA1c, weight and BMI, blood pressure, eGFR, urine albumin-to-creatinine ratio, lipids. The foot examination needs its components named (skin, pulses, monofilament or vibration sense), not just "feet normal".
A states control against the patient's own target, which complications are present or excluded, and any risk category such as foot risk. P lists every diabetes medicine with dose, the reason for any change, sick-day advice given, referrals (eye screening, dietitian, podiatry, education), and when each test will be repeated.
Example: new diagnosis
S: 46-year-old man, HbA1c 55 mmol/mol (7.2%) on routine bloods, repeat 57 mmol/mol (7.4%). Asymptomatic. Office job, little exercise. Mother has diabetes. O: BMI 30.8. BP 128/80. eGFR above 90. Urine albumin-to-creatinine ratio normal. Feet normal, monofilament intact. A: Type 2 diabetes, new, no complications found. P: Diagnosis explained. Structured education course referral. Start metformin 500 mg once daily with food, increase over 4 weeks as tolerated. Eye screening referral. Lipids and 10-year risk at next visit. Review in 3 months with HbA1c.
Documentation gaps that come up in diabetes reviews
- HbA1c given without the previous value or the individual target, so the trend is invisible.
- Foot check written as normal with no components, which does not show a risk category.
- Hypoglycemia not asked about when a sulfonylurea or insulin is used.
- Sick-day advice for SGLT2 inhibitors or metformin not written down as given.
- Eye screening status missing.
- Units missing on HbA1c; mmol/mol and percent are both in use.
ICD-10 codes for type 2 diabetes
| Code | Meaning |
|---|---|
| E11.9 | Type 2 diabetes mellitus without complications |
| E11.65 | Type 2 diabetes mellitus with hyperglycemia |
| E11.22 | Type 2 diabetes mellitus with diabetic chronic kidney disease |
| E11.40 | Type 2 diabetes mellitus with diabetic neuropathy, unspecified |
| E11.3 (subcategory) | Type 2 diabetes mellitus with ophthalmic complications; the full code depends on retinopathy type and eye |
| Z79.84 | Long-term (current) use of oral hypoglycemic drugs |
These are ICD-10-CM codes. Systems on the base ICD-10 list use four-character E11 codes, so check which version your EMR expects.
From the visit to the note with ClearPass
Diabetes reviews produce many values in one conversation. With Transcribe on (after the patient agrees), ClearPass sorts what was discussed into SOAP: medicines and symptoms in S, values and the foot exam in O, control and complications in A, changes and referrals in P. Choose Concise for a short review note or Detailed when you want every value kept.
If the note shows an HbA1c or eGFR that nobody said aloud, the numbers check marks it for review. The E11 code is one click away, as are patient instructions for sick-day rules and a referral letter to a dietitian or eye service. It is still an AI draft, and you review it before it goes anywhere.
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 does the foot examination go in a diabetes SOAP note?
In Objective, with each component named: skin, pulses and sensation testing. The resulting foot risk category belongs in Assessment.
Should the HbA1c be in percent or mmol/mol?
Use the unit your laboratory reports and write it every time. Giving both, as in the example, avoids confusion when notes are read elsewhere.
Can ClearPass add the diabetes ICD-10 code for me?
It suggests ICD-10 codes from the note with one click. Check the suggestion against the complications you actually documented, because the specific E11 code depends on them.
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