AI SOAP Notes for Acute Care & Hospital Therapy

Automate your inpatient therapy documentation. Save hours every week with AI-powered clinical notes that understand acute care assessments, discharge planning, and hospital-specific requirements for PT, OT, and SLP.

Try Free for 3 Days
  • Works with Epic, Cerner, Meditech, and any EHR
  • HIPAA compliant
  • $49/month
HIPAA Compliant
PHI Auto-Removed
Works With Any EHR
Cancel Anytime

Acute Care Documentation Challenges

Hospital-based therapists face relentless productivity demands. You're treating 10-15 patients daily across multiple units, managing complex medical cases, coordinating discharge planning, and documenting in an EHR that wasn't designed for therapy. Between ICU patients, post-surgical cases, and complex medical comorbidities, documentation can easily consume your entire shift. There's a better way.

Without SOAP Note Buddy

  • Staying late to finish daily notes
  • Rushing through documentation between patients
  • Copy-pasting notes and risking errors
  • Missing documentation for complex medical cases

With SOAP Note Buddy

  • Generate complete notes in seconds
  • Document at the bedside or between patients
  • Each note personalized to that specific patient
  • Capture medical complexity accurately

Why Acute Care Therapists Love SOAP Note Buddy

Hospital therapy documentation is uniquely challenging. Your patients have complex medical histories, multiple comorbidities, and rapidly changing conditions. SOAP Note Buddy understands acute care contexts - from ICU mobilization to discharge planning - and generates documentation that captures the medical complexity your patients require.

Understands Medical Complexity

Multi-system involvement, comorbidities, precautions, and contraindications. The AI captures the medical context that acute care documentation requires.

High-Volume Days

Seeing 12-15 patients daily? Generate notes quickly between patients to stay caught up, even on your busiest days.

Discharge Planning Focus

Automatically incorporates discharge recommendations, equipment needs, and level of care recommendations into your documentation.

How It Works for Acute Care

1

Add Your Patient

Enter the patient's admission info - diagnosis, surgical procedures, medical history, precautions, functional status, and therapy goals. This is stored locally on your device (never on our servers).

2

Open Your EHR

Navigate to Epic, Cerner, Meditech, or any web-based hospital EHR. SOAP Note Buddy automatically detects the documentation fields in your therapy note template.

3

Click Generate

One click generates personalized daily notes based on your patient's specific medical status, functional progress, and therapy interventions.

4

Review & Submit

Review the AI-generated content, make any needed adjustments for that day's specific findings, and submit. Documentation that used to take 15-20 minutes now takes 2-3.

Features for Acute Care

Acute Care-Specific Templates

Documentation templates for evaluations, daily notes, progress notes, and discharge summaries. Understands hospital therapy requirements and terminology.

Works With Epic, Cerner & More

Automatically detects and fills fields in Epic, Cerner, Meditech, Allscripts, and any other browser-based hospital EHR system.

HIPAA Compliant

PHI is automatically removed before AI processing. Patient names, MRNs, DOBs, and identifiers never leave your device.

Save 10+ Hours/Week

Hospital therapy documentation that used to take hours now takes minutes. More time for patient care, less time charting after your shift.

Captures Medical Complexity

Multiple diagnoses, surgical procedures, medical precautions, lines and tubes, weight-bearing status - the AI understands acute care terminology.

Discharge Recommendations

Automatically generates discharge planning notes, equipment recommendations, and level of care suggestions based on patient progress.

Acute Care SOAP Note Examples

Hospital PT: Post-Surgical Hip Fracture

Scenario: 78-year-old patient, post-op day 2 following ORIF right hip fracture. Medical history includes HTN, DM2, and mild dementia. Currently on telemetry with TTWB precautions.

S - Subjective

Patient reports "I want to get out of this bed." Rates pain at 5/10 at rest, 7/10 with movement. Patient denies shortness of breath or dizziness. Family reports patient was independent with ambulation using cane prior to fall. Patient oriented to name and place, intermittently oriented to time.

O - Objective

Vital Signs (pre-treatment): BP 138/82, HR 78, SpO2 96% RA, RR 16.
Lines/Tubes: Peripheral IV L arm, Foley catheter, telemetry.
Bed Mobility: Supine to sit with mod A x1, cueing for hip precautions.
Transfers: Sit to stand with mod A x1, front-wheeled walker, TTWB RLE per orthopedics.
Gait: Ambulated 25 feet with FWW, mod A x1 for balance and weight-bearing compliance. Gait pattern slow, guarded, with decreased step length bilaterally.
Balance: Sitting static good, dynamic fair. Standing static fair, requires UE support.
Vitals (post-activity): BP 142/86, HR 92, SpO2 94% RA (recovered to 97% within 2 min).

A - Assessment

Patient is functioning below prior level due to R hip ORIF with associated pain, weakness, and fear of falling. Patient demonstrates moderate cognitive impairment affecting ability to follow hip precautions independently. Requires skilled PT for mobility training, gait training, therapeutic exercise, and patient/family education to optimize safety and function for discharge.

P - Plan

Continue acute PT daily for bed mobility, transfers, gait training with assistive device. Progress ambulation distance as tolerated. Coordinate with nursing for mobility schedule. Family education on hip precautions and fall prevention. Recommend discharge to SNF for continued rehabilitation given cognitive impairment, fall risk, and need for 24-hour supervision. Will reassess weight-bearing status with orthopedics at follow-up.

Hospital OT: CVA with Left Hemiparesis

Scenario: 65-year-old patient, day 5 post right MCA CVA with resulting left hemiparesis. Patient is medically stable, being evaluated for discharge disposition.

S - Subjective

Patient reports "I can't do anything with my left arm." Expresses frustration with functional limitations. Denies pain. Patient states he was independent with all ADLs prior to CVA and is motivated to return home. Wife present and reports willingness to assist with care at home.

O - Objective

Cognition: Alert and oriented x4. Follows 2-step commands. Mild left neglect noted on scanning tasks.
UE Status: L shoulder flexion 3-/5, elbow flexion 3/5, wrist extension 2/5, grip strength trace. Sensation diminished L UE.
ADL Performance: Grooming with min A for setup and cueing to address left side. Upper body dressing with mod A for L sleeve management. Feeding with min A for setup, uses adaptive equipment (rocker knife, scoop plate).
Transfers: Bed to wheelchair with min A x1, stand pivot. Toilet transfer with min A x1.
Treatment: ADL training, L UE AROM/PROM, compensatory strategies for left neglect, caregiver training.

A - Assessment

Patient demonstrates moderate functional limitations in ADLs due to L hemiparesis and mild left neglect. Patient is making progress with compensatory strategies and demonstrates good safety awareness with cueing. Family support available for discharge. Skilled OT continues to be medically necessary for ADL training, L UE remediation, compensatory strategy training, and caregiver education.

P - Plan

Continue acute OT daily for ADL training and L UE function. Progress to lower body dressing and bathing tasks. Continue L neglect scanning strategies. Complete home safety assessment with case management. Recommend home health OT at discharge if returning home, or IRF if patient requires higher level of rehabilitation. Order adaptive equipment: long-handled sponge, reacher, sock aid for discharge. Caregiver training session scheduled for tomorrow.

These examples were generated by SOAP Note Buddy in under 10 seconds each.

Works for All Hospital Therapy Disciplines

Whether you're a physical therapist, occupational therapist, or speech-language pathologist working in the acute care setting, SOAP Note Buddy adapts to your documentation needs.

Physical Therapy (PT)

Mobility assessments, gait training, bed mobility, transfers, therapeutic exercise, balance training. Documentation that captures acute PT interventions and discharge planning.

Occupational Therapy (OT)

ADL assessments, self-care training, UE function, cognitive screening, adaptive equipment recommendations. Hospital OT documentation made efficient.

Speech-Language Pathology (SLP)

Swallow evaluations, dysphagia management, cognitive-linguistic assessments, voice therapy, aphasia treatment. Acute SLP documentation simplified.

ICU Mobility

Early mobilization documentation, ventilator weaning support, sedation vacation coordination. Specialized notes for critical care therapy.

Works Across All Hospital Units

From the ICU to the step-down unit, from orthopedics to oncology, SOAP Note Buddy understands the unique documentation requirements for each patient population.

ICU/Critical Care

Early mobility protocols, sedation levels, ventilator status, hemodynamic monitoring. Documentation for your most medically complex patients.

Medical/Surgical

Post-surgical mobility, medical complexity, precautions, and discharge planning. The bread-and-butter of acute care therapy.

Orthopedics

Weight-bearing status, hip/knee precautions, post-surgical protocols. Orthopedic-specific terminology and restrictions.

Cardiac/Pulmonary

Telemetry monitoring, cardiac precautions, pulmonary rehabilitation. Documentation that captures cardiopulmonary considerations.

Simple, Affordable Pricing

No contracts. No setup fees. Cancel anytime.

Monthly Price $49/month
Free Trial 3 days
EHR Support Any web-based
Credit Card Required Yes, for trial
Compare Our Pricing

Most AI scribes charge $99-$299/month. SOAP Note Buddy is $49/month with no contracts. That's $600+/year in savings. The time you save on just two patients per day pays for the entire month.

Ready to Save Hours on Hospital Documentation?

Join acute care therapists who've stopped staying late to finish notes. Try free for 3 days.

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Acute Care FAQ

Does SOAP Note Buddy work with Epic and Cerner?

Yes! SOAP Note Buddy works with Epic, Cerner, Meditech, Allscripts, and any other browser-based hospital EHR. It automatically detects fields in your therapy note template and fills them with AI-generated content.

Does it understand acute care medical terminology?

Yes. SOAP Note Buddy understands hospital-specific terminology including weight-bearing precautions, lines and tubes, telemetry, cardiac precautions, ventilator status, surgical procedures, and medical comorbidities. It generates clinically appropriate documentation for complex inpatients.

How does SOAP Note Buddy protect patient information?

PHI is automatically scrubbed before any data is sent to AI processing. Patient names, MRNs, DOBs, room numbers, and other identifiers are removed locally on your device. We're HIPAA compliant and offer a Business Associate Agreement (BAA).

Can I use it for high-volume acute care days?

Absolutely. SOAP Note Buddy is designed for high-productivity settings. Generate notes between patients, at the nursing station, or wherever you document. Many acute care therapists report eliminating after-shift documentation entirely.

Does it work for evaluations and discharge summaries?

Yes. SOAP Note Buddy can generate content for evaluations, daily treatment notes, progress notes, and discharge summaries. It adapts to your specific documentation template and note type.

How much time will I actually save?

Most acute care therapists report saving 10-15 hours per week on documentation. Daily notes that took 15-20 minutes now take 2-3 minutes. That's time back in your day - no more staying late to finish charting.

Is there a free trial?

Yes! 3-day free trial. A credit card is required but you won't be charged if you cancel within 3 days. No pressure, no sales calls.