SOAP guide
Subjective
What the patient tells you. Today ArkCloud stores only current pain - score, where, which side and the trend since the last visit - as structured data on a visit note. Everything else in the patient's history is written as text, or recorded through body-map items and guided questions where a matching one exists.
Written for: Physical therapists · Occupational therapists · Speech-language pathologists · Evaluators
What is structured today
| Capability | Status | What that means here |
|---|---|---|
| Structured pain and patient report (visit notes) | Available | Pain now on 0-10, where, which side, and better, unchanged or worse since the last visit; up to six short statements of what the patient reports; and a free-text change since the last visit. |
| Structured history fields (chief complaint, onset, pain best and worst, sleep, headaches) | In development | Separate fields for chief complaint, mechanism of onset, best and worst pain, sleep and headaches are being built. Today these are written in the note's free-text sections, or recorded through body-map items and guided questions where those exist. |
On a visit note, Quick Capture holds three Subjective controls:
- Pain today (0-10): a score from 0 to 10, Where (shoulder, elbow, forearm, wrist, hip, knee, ankle, cervical, lumbar, thumb, the fingers, thoracic, neck, low back, hand, foot or other), Side (left, right, bilateral or not applicable) and Since last visit (better, unchanged or worse). Each starts as "Not recorded".
- What the patient reports: up to six short statements in the patient's terms, 160 characters each.
- Changes since the last visit: one free-text line of up to 400 characters, under "More".
Evaluations (Initial Evaluation, Re-evaluation) have no Quick Capture. Their subjective content is written in Reason for referral / presenting concern, Relevant history and, for a re-evaluation, Interval history since last evaluation.
How each subjective item is recorded
Exactly how each common subjective item can be recorded today. "Free text" means you write it in the note section; nothing is structured or searchable for it.
| Item | How it is recorded | Where |
|---|---|---|
| Chief complaint | Free text. On a visit note, the short "What the patient reports" statements hold it in the patient's words. A separate chief-complaint field is in development. | Reason for referral / presenting concern (evaluations); Subjective (visit note). |
| Medical history | Free text, plus body-map item or guided questions for history at the site: Previous surgery at this site, Previous injury at this site, Recurrent episodes, Previous corticosteroid injection, Imaging available, Previous physiotherapy for this problem, History of falls. | Relevant history (evaluations); the body map's Relevant history list. Allergies, medications and problems are kept on the patient's chart. |
| Onset and mechanism | Body-map item or guided question: "Did this start with a specific injury or incident?" and its follow-up about significant trauma; treatment context items such as Post-injury, Post-operative, Work-related and Sport-related. A body-map symptom recorded in detail can carry an onset type (Acute, Gradual, Insidious, Post-surgical, Traumatic). The mechanism itself is free text. | Body map; Reason for referral or Relevant history. |
| Pain, current | Structured field: 0-10 with region, side and trend since the last visit. A body-map symptom recorded in detail can also carry a 0-10 severity. | Quick Capture on the visit note; body map. |
| Pain, best and worst | Free text. Best and worst pain fields are in development. | Subjective (visit note); Reason for referral or Relevant history (evaluations). |
| Duration and behaviour of symptoms | Free text, plus the guided question "Does pain wake the patient at night?" (with a red-flag follow-up about constant night pain), the symptom item Pain at night, and the treatment context items Acute flare and Chronic / persistent. | Body map; note text. |
| Functional limitations | Body-map item or guided question: each region has its own Functional limitations list (for example Difficulty with stairs, Difficulty reaching overhead, Difficulty turning the head to drive). Otherwise free text. | Body map; Functional limitations (evaluations); patient report on the visit note. |
| Sleep and positioning | Body-map item or guided question where one exists: "Is sleeping on this side difficult?" (shoulder) and the item Difficulty sleeping because of symptoms (cervical, lumbar, shoulder, hip). Otherwise free text. A sleep field is in development. | Body map; note text. |
| Headaches and neurological symptoms | Body-map item or guided question: Cervicogenic headache (cervical spine, head), Tension-type headache (head), Dizziness, Numbness, Tingling, Radiating pain; arm or leg pins-and-needles questions; red-flag screens for progressive weakness or numbness and symptoms in both arms or both legs. A headache field is in development. | Body map; note text. |
| Home environment | Free text. | Note text. Home-health episodes add a Home environment & safety section; OT notes have Adaptive equipment & environmental adaptation. |
| Occupation and activity demands | Free text, plus "Is it related to work?" and the items Reduced tolerance for work duties and Reduced sport participation. | OT Occupational profile; body map; note text. |
| Other screening questions | Body-map item or guided question: falls in the past year, previous surgery, recurrence, and red-flag screens (unexplained weight loss, history of cancer, fever or feeling unwell, and region-specific screens). | Body map. |
Manual entry
- On the visit note, open Document this visit.
- Tap the pain score, then choose Where, Side and Since last visit. Leave any of them at Not recorded if the patient did not say.
- Type each thing the patient reports in their terms and press Enter after each one.
- If something changed since the last visit, add it under More: changes since last visit.
- Write anything else in the Subjective - patient report section, or press Build from your selections (no AI) and insert the Subjective sentences it writes.
Example (synthetic patient)
PT, outpatient knee
Selections: pain 5, Where knee, Side left, Since last visit better. Patient reports "stiff after sitting".
Build from your selections writes: "Patient reports left knee pain 5/10, better since the last visit. Patient reports: stiff after sitting."
AI-assisted entry
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.
The draft's Subjective may only use what was recorded for today: your Quick Capture selections, your typed visit notes and your dictated summary. A clinician measurement or assistance level written into Subjective is removed, because those are observed, not reported. Anything the patient did not say stays missing; the draft does not fill it in.
Voice-assisted entry
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.
Where voice is switched on, a visit recording is added to the visit-notes box under an "unverified" heading for you to review; it is not a Subjective field. On an evaluation recording, the proposed entries are guided-screening answers, range of motion, strength and assistance levels - not pain best or worst, and not history.
OT and SLP
The same controls appear on OT and SLP visit notes. OT notes add an Occupational profile section and SLP notes a Communication section, both free text. SLP subjective content (for example the patient's report of coughing at meals) is written as text or as a short patient-report statement; the body map is musculoskeletal and has no swallowing or communication region.
Troubleshooting
- Cannot add a seventh statement: the limit is six. Combine them or write the rest in the Subjective section.
- No pain controls on an evaluation: expected. Write pain in the evaluation's sections, or record a symptom in detail on the body map.
- Last visit's pain is not shown: by design. Earlier values are never copied into a new note.