SOAP note example: urinary tract infection
Most urinary tract infection visits are simple cystitis, but the note has to show the checks that make it simple: pregnancy status, fever, flank pain and risk factors for resistance. The invented notes below cover an uncomplicated case and an upper tract infection, followed by what belongs in each section and the codes that usually apply.
Example: uncomplicated cystitis
S: 29-year-old woman, 2 days of dysuria, frequency and urgency. Suprapubic discomfort. No visible blood. No fever, rigors, flank pain, nausea or vomiting. No vaginal discharge or itch. Last menstrual period 2 weeks ago, uses combined pill, pregnancy unlikely. One UTI 18 months ago. No antibiotics in the last 3 months. No known allergies. No diabetes or kidney problems. O: Temp 36.9, pulse 76, BP 118/74. Abdomen soft, mild suprapubic tenderness, no renal angle tenderness. Urine dipstick: nitrite positive, leukocytes 2+, blood trace, protein negative. Urine pregnancy test negative. A: Acute uncomplicated cystitis. No features of upper tract infection. P: 1. Nitrofurantoin modified-release 100 mg twice daily for 3 days. 2. Urine culture not sent (typical presentation, no recent antibiotics). 3. Fluids and paracetamol for discomfort. 4. Return if not improving in 48 hours, or same day for fever, flank pain, vomiting or feeling very unwell. 5. If symptoms recur within 4 weeks, send a urine culture.
What to put in each part of a UTI note
- Subjective: the lower tract symptoms and duration, visible blood, and the upper tract questions (fever, rigors, flank pain, vomiting). Vaginal symptoms, which point elsewhere. Pregnancy status or possibility, catheter use, recent antibiotics or hospital stay, previous infections, diabetes, kidney disease and allergies. For men, prostate symptoms.
- Objective: temperature, pulse and blood pressure, abdominal and renal angle examination, dipstick results named individually, pregnancy test where relevant, and whether a culture was sent.
- Assessment: lower versus upper tract, and uncomplicated versus complicated (pregnancy, male sex, structural abnormality, catheter, immunosuppression, treatment failure).
- Plan: antibiotic with dose and duration, or a decision not to treat with the reason, culture yes or no, analgesia, and specific return symptoms.
The words "uncomplicated" and "complicated" carry the decision in a UTI note. If the note calls it uncomplicated, the facts above it should support that.
Example: suspected pyelonephritis
S: 36-year-old woman, 3 days of dysuria, now fever, rigors and right loin pain since yesterday. Nausea, kept fluids down today. Not pregnant (test negative). O: Temp 38.6, pulse 104, BP 112/70, RR 18. Right renal angle tenderness. Dipstick nitrite and leukocytes positive. A: Acute pyelonephritis, right. Tolerating oral fluids, no signs of sepsis at present. P: Urine sent for culture. Oral antibiotic per local resistance guidance, 7 days. Bloods today. Review in 24 hours by phone; hospital if vomiting, confused, low blood pressure or not improving in 48 hours.
What UTI notes often miss
- Pregnancy status not asked or not written.
- No statement that fever and flank pain were asked about.
- Dipstick written as "positive" without saying which markers.
- Recent antibiotic use not asked, although it changes the choice.
- Culture decision missing, especially in men, recurrent infection and treatment failure.
- Antibiotic duration left out of the plan.
ICD-10 codes for urinary infections
| Code | Meaning |
|---|---|
| N39.0 | Urinary tract infection, site not specified |
| N30.00 | Acute cystitis without hematuria (ICD-10-CM) |
| N30.01 | Acute cystitis with hematuria (ICD-10-CM) |
| N10 | Acute pyelonephritis (ICD-10-CM wording; base ICD-10 calls N10 acute tubulo-interstitial nephritis) |
| R30.0 | Dysuria, when infection is not confirmed |
An organism code (B95 to B96 range) can be added when culture identifies it. Base ICD-10 uses N30.0 for acute cystitis without the extra digit.
How ClearPass handles a UTI visit
A UTI consultation is mostly questions, and the negatives are what make the note useful. Transcribe, used after the patient agrees, keeps the questions you asked about fever, loin pain and pregnancy, and ClearPass places the answers in the S section of a SOAP draft. The dipstick and observations go to O; your lower or upper tract judgement goes to A.
The numbers check marks any temperature or dose in the note that was not said. N39.0 or the cystitis code is one click away. Patient instructions covering fluids, the antibiotic course and return symptoms are another click, and so is a referral if recurrent infection needs a urology opinion. Review 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
Is it enough to write 'dipstick positive' in a UTI note?
It is better to name each marker, such as nitrite positive and leukocytes 2+, because nitrite and leukocyte results carry different weight.
When is a UTI documented as complicated?
Commonly in pregnancy, in men, with catheters, structural or functional urinary tract problems, immunosuppression, or upper tract features. State the reason in the Assessment.
Does ClearPass choose the antibiotic?
No. It does not make clinical decisions. It writes the drug, dose and duration you stated, and marks numbers that were not in the transcript.
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