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SOAP Note Generator From Visit Notes
Paste your shorthand, dictation or visit transcript and get a SOAP note with only what you documented, and every gap marked to confirm.
River's SOAP note generator turns what you already wrote down into a note you can sign. Paste shorthand, a dictation or a visit transcript, and it comes back sorted into subjective, objective, assessment and plan, written in full sentences, with abbreviations expanded only where they are unambiguous. Each problem gets its own assessment and plan. Anything you did not document, from a missing allergy list to an exam you did not describe, is marked for you rather than filled in.
Most SOAP note generators complete the note for you. Give them a chief complaint and they return a full review of systems and a normal examination you never performed. That reads well and is a false record, and auditors treat templated text that does not match the visit as a problem. This one does the opposite. It never adds a finding, a vital sign or a dose that is not in your notes, and it flags safety issues for you to decide.
This is for physicians, nurse practitioners, physician assistants, residents and students who see the visit clearly but lose the evening to typing it all up afterwards. Paste the note into your record system once you have checked it. A procedure done during the visit gets its own procedure note. If a stack of outside records came with the patient, build an outside records chronology first. To audit notes across a whole clinic rather than write one, use the documentation gap review instead.
What a visit note needs since the 2021 coding changes
Office visit coding changed in 2021. For office and outpatient visits, the level is now chosen by medical decision making or total time on the date of the visit, and the history and exam only need to be medically appropriate. A long review of systems no longer raises the level. What supports it is the assessment and plan: the problems addressed and how serious they are, the data reviewed or ordered, and the risk of the management chosen.
That changes what a good note looks like. Take an illustrative follow-up for high blood pressure and diabetes. The note that supports the visit says blood pressure is above goal on the current dose and the A1c rose from 7.4 to 8.1. It records that the clinician raised lisinopril from 10 to 20 mg daily and ordered a metabolic panel in two weeks to check potassium and kidney function. Two chronic problems, one worsening, and a prescription change: the plan carries the visit.
Copied and templated text is the opposite risk. The HHS Inspector General has warned that electronic record features such as copy and paste can distort the record and inflate claims, and Medicare contractors have treated cloned notes as failing to show medical necessity. A note built only from what was actually said and found avoids both problems. It is usually shorter, it matches the visit, and every line in it can be defended if anyone asks.
How it works
Paste your notes
Shorthand, a dictation or a visit transcript, plus anything about the setting or your preferred format.
River sorts it
Each statement placed in the right section and written out, with nothing added that you did not say.
Check the gaps
Every marked gap and safety flag is listed at the top, so nothing gets signed by accident.
Paste into your record
Copy the checked note into your record system, or ask in chat for a shorter version.
What you get
- Subjective, objective, assessment and plan sorted from your shorthand, dictation or a visit transcript
- A separate assessment and plan for each problem, in the order you addressed them
- Only the findings, vital signs and doses you documented, with nothing normal filled in by default
- Gaps such as missing allergies or an undescribed exam listed for you to confirm before signing
- Safety flags for red-flag symptoms, dose concerns or likely interactions, left for your decision
- A short note on which visit coding elements the plan documents, without choosing a level
Common questions
Will it fill in a normal exam or review of systems?
No. It writes only the systems and exam findings you documented. If your notes say nothing about the lungs, the note says nothing about the lungs, and the gap list asks whether you examined them. Pre-filled normal findings are the most common way generated notes misstate what actually happened in the room.
Does it choose the visit level for billing?
No. It can list which elements of medical decision making the note documents, such as the problems addressed, the data reviewed and the risk of treatment, so you can check the note supports the level you choose. Selecting the code is yours or your coder's, and the note is never padded to reach a higher level.
Can I paste a recorded visit transcript?
Yes, if the recording followed your organization's consent policy. River separates what the patient reported from what you found and decided, and leaves out small talk. Anything on the recording that conflicts with your own notes is flagged for you rather than chosen silently, because the signed note has to match your judgement.
What happens with medication changes?
They are written exactly as you gave them: drug, dose, route, frequency and what changed. If a dose looks unusual, an interaction is likely with the current list, or the allergy list is missing, River flags it for you to check. It never corrects a dose or adds a medication on its own.
Can I include patient identifiers?
Follow your organization's policy. River is HIPAA-eligible, and identifiable notes belong in an account covered by a Business Associate Agreement. Without one, write the note from age, sex and the clinical facts only, and add the name and record number in your own system. The note reads the same either way.
Does it work for hospital progress notes?
Yes. Choose the hospital progress note option. The subjective section covers overnight events, the objective section lists vital signs, intake and output, and results with the times you gave, and the plan runs problem by problem with the day's changes first. A discharge summary is a different document with its own structure.
Sources
Built by
Chandler Supple
Co-founder & CEO, River
Chandler has spent the last six years working in AI, building tools for millions of users and Fortune 100 companies. In 2025, he co-founded River to build a new kind of operating system for AI agents.
SOAP Note Generator From Visit Notes
Describe what you need, add any files you have, and your workspace opens with the work already underway.