SOAP guide
Assessment
Your clinical interpretation of what you recorded. The Assessment is always your judgement and is written as text; ArkCloud helps by showing confirmed findings, earlier values beside today's, and what is still missing. It never adds a conclusion the record does not support.
Written for: Physical therapists · Occupational therapists · Speech-language pathologists · Clinical leads
Where the assessment goes
| Note type | Assessment section |
|---|---|
| Visit note | Assessment - response & progress toward goals |
| Initial Evaluation | Clinical assessment (with Functional limitations alongside) |
| Re-evaluation | Re-assessment findings; Clinical assessment |
| Progress Report | Progress toward goals; Reassessment findings |
| Discharge Summary | Goals met / outcomes |
What a supported assessment draws on
| Content | What ArkCloud gives you to support it |
|---|---|
| Impairments | Today's range of motion and MMT values, special test results and confirmed examination findings from the body map. |
| Functional limitations | Confirmed functional-limitation findings, mobility observations with assistance levels, and activities with the help needed. |
| Clinical interpretation | Nothing automatic. This is your reasoning. |
| Response to treatment | The tolerance answer in Quick Capture: Tolerated without reported difficulty, Increased discomfort, Required modification, or Other / document response (your words required). |
| Progress, when supported | Each goal marked Progressing, No change, Regressed, Met or Not assessed today, and the earlier value beside today's for each measurement. |
| Rationale for continued care | Accepted goals, the active plan of care and the remaining gap between baseline and target. The rationale itself is yours. |
Using confirmed findings
Confirmed findings into the noteAvailable
Body-map and mobility findings you have confirmed are shown as text first and then placed into the matching note section when you choose to add them. Selected-but-unconfirmed findings never reach a note.
- Confirm the body-map and mobility findings on the episode that you want to rely on. Selected-but-unconfirmed findings are never offered.
- In the note, open Confirmed findings from the body map and mobility. The exact text is shown before anything is added.
- Add it. Each finding goes to the matching section (for example functional limitations to Functional limitations, mobility to Mobility, transfers & gait). Anything without a matching section is listed as left out.
- Write your interpretation around it. Nothing is signed for you.
Checking what the assessment can rest on
What Assessment and Plan still needAvailable
On a visit note, before any draft, ArkCloud lists what Assessment and Plan can rest on, what is missing (accepted goals, a plan of care, an earlier value, the patient's response, today's functional status) and today's measurements beside earlier values. Fixed rules, no AI.
On a visit note, ArkCloud lists any of these gaps, each with a question you can answer:
- "No accepted goals on this episode, so the assessment cannot relate today's findings to goals."
- Proposed goals waiting for acceptance, which are not used until accepted.
- "No active plan of care, so response to the planned treatment cannot be judged."
- No earlier value for a measurement taken today, "so change cannot be stated."
- "How the patient responded to today's treatment is not recorded."
- "No functional status recorded today (an activity performed, the assistance needed, or goal progress)."
Above the list, Baseline and today shows each of today's measurements with the earlier value and its date, and the goal's baseline and target if a goal measures it. These are recorded numbers, not a judgement.
Example (synthetic patient)
PT, left knee, visit 6
Baseline and today: AROM left knee flexion - today 105, earlier 92 (date of the earlier visit), goal baseline 92, target 120.
A supported assessment might read: "Left knee flexion AROM 105 degrees, previously 92; progressing toward the 120-degree goal. Tolerated without reported difficulty. Continued skilled care indicated for stair negotiation (contact guard today)." The last sentence is your rationale; ArkCloud does not write it.
What AI can do in the Assessment today
| Capability | Status | What that means here |
|---|---|---|
| AI-assisted SOAP draft (visit notes) | Available with configuration | Proposes Subjective, Objective, Assessment and Plan text from what is recorded for the visit. The draft appears beside the note; you insert, edit or ignore each section, and signing an AI-assisted note asks you to confirm you reviewed it.Requires: Your organisation's AI switch turned on by an administrator and, where your clinic uses the patient AI agreement, the patient's signed yes to AI-assisted notes. Drafting itself is switched on for the hosted service. |
| Checks on AI-drafted text | Available | Every drafted sentence is checked against what was recorded. A number, side or assistance level that is not in the record is removed, negation and uncertainty must survive, and an Assessment with nothing recorded today is left blank. The checks catch invented facts, not clinical correctness. |
- Draft wording from recorded facts. On a visit note, Draft SOAP note can propose Assessment text from today's recorded findings, your own typed assessment, accepted goals, the plan of care, the previous signed note's assessment and plan, earlier measurements and entered outcome scores. Each source is labelled today, standing or earlier.
- Leave it blank when nothing supports it. An Assessment that cites nothing recorded today is emptied, and the reason is shown.
- Remove unsupported sentences. A sentence with a number, side or assistance level not in the record, or that drops a "not" or a "possible", is removed and the count is shown. A number from an earlier visit must be labelled as earlier ("previously", "last visit" or a date).
- Progress reports and discharge summaries. The narrative draft writes Progress toward goals, Reassessment findings, Course of care and Goals met / outcomes from recorded facts, and may not say a patient improved, declined or plateaued. See AI-assisted SOAP drafting.
AI does not diagnose, does not decide whether care continues, and is not available on the Initial Evaluation or Re-evaluation. Drafting has been exercised on synthetic PT and OT visits; behaviour on speech-language pathology visits has not been independently verified, so review SLP drafts with particular care.
Manual and voice-assisted entry
Write the Assessment section yourself at any time, or type your assessment into Your assessment under "Type or dictate notes" so a draft builds on it. Build from your selections (no AI) puts only your typed assessment and your goal-progress selections into Assessment; it writes no interpretation of its own.
Voice-assisted entryLimited preview
Visit recording and spoken summaries on visit notes, and evaluation recording with proposed entries, are built but not released for routine use. A transcript or proposal never enters a note until you review it and insert or accept it.
Requires: Released to an organisation only after clinical, legal and accuracy sign-off.
Voice never proposes an impression, diagnosis or assessment. A dictated summary can be a source for the AI draft, under the same checks.
Troubleshooting
- The draft left Assessment blank: nothing recorded today supports it. Record findings, tolerance or goal progress, or write the assessment yourself.
- "none recorded" under Earlier: no earlier value exists for that measurement. Record the baseline, or set a goal with a baseline.
- A body-map finding is not offered for the note: it has not been confirmed.