SOAP Note Templates - Paw & Care

The Template Management system allows customization of AI-generated SOAP note structure, field definitions, and detail levels to match your practice’s documentation standards.

Overview

Templates define how the AI assistant structures clinical documentation, including:

Required and optional fields for each SOAP section
Level of detail in generated notes
Specialized formats for different visit types
Custom field types and dropdown options

Templates primarily control AI note generation. They do not restrict manual documentation entry by veterinarians.

Template Library

The system includes built-in templates for common use cases:

SOAP - General

Type: soapStandard subjective-objective-assessment-plan format for general practice visitsDetail level: ConciseBest for: Wellness exams, routine sick visits, follow-ups

SOAP - Specialist

Type: soap_specialistExtended SOAP format with additional specialty fieldsDetail level: DetailedBest for: Cardiology, oncology, internal medicine referrals

Dental - Canine

Type: dental_canineStructured dental chart with tooth-by-tooth assessmentDetail level: DetailedBest for: Dog dental cleanings, extractions, oral surgery

Dental - Feline

Type: dental_felineFeline-specific dental documentation with FORL trackingDetail level: DetailedBest for: Cat dental procedures, stomatitis cases

Radiograph Report

Type: radiographStructured imaging interpretation templateDetail level: DetailedBest for: X-ray, ultrasound, CT/MRI documentation

Surgery Report

Type: surgery_reportPre-op, intra-op, and post-op documentationDetail level: DetailedBest for: Surgical procedures requiring anesthesia

Additional Template Types

Specialty Templates

Formatted Dictation (formatted_dictation): Free-form voice dictation with light formatting
Callback Note (callback): Client callback documentation and follow-up items
Tech Appointment (tech_appointment): Technician-only visits (vaccines, nail trims)
Staff Meeting (staff_meeting): Team meeting minutes and action items
Rounds (rounds): Daily patient rounds and treatment updates
Lecture Note (lecture_note): CE/training session documentation
Custom (custom): User-created templates for practice-specific needs

Template Interface

The template management screen has two main sections:

Template List (Left Sidebar)
Template Preview (Right Panel)

List Components

Search bar: Filter templates by title
Template cards: Each showing:
- Drag handle icon (for reordering)
- Template title
- Default badge (if set as default)
- “Built-in” label
- Edit icon (on hover)
- Chevron arrow

<button className="w-full flex items-center gap-3 px-3 py-3 rounded-lg">
  <GripVertical className="h-4 w-4" />
  <div className="flex-1">
    <span className="font-medium text-sm">{template.title}</span>
    {template.isDefault && (
      <Badge variant="secondary">
        <Star className="h-3 w-3 mr-0.5" /> Default
      </Badge>
    )}
  </div>
  <ChevronRight className="h-4 w-4" />
</button>

Empty State

When no templates are selected, the right panel displays:

Document icon illustration
“Tips & Templates” heading
Explanation of template purpose and usage

Preview Components

Header:

Template title (in primary color)
Description text
“Make default” button (if not already default)
“Copy and customize” button for creating variants

Detail Level Toggle:

<Tabs value={activeDetail} onValueChange={setActiveDetail}>
  <TabsList>
    <TabsTrigger value="concise">
      More concise
      {template.detailLevel === 'concise' && (
        <Badge>Recommended</Badge>
      )}
    </TabsTrigger>
    <TabsTrigger value="detailed">
      More detail
      {template.detailLevel === 'detailed' && (
        <Badge>Recommended</Badge>
      )}
    </TabsTrigger>
  </TabsList>
</Tabs>

Section List: Scrollable display of all template sections and fields

Detail Levels

Templates support two AI generation modes:

Concise

Characteristics:

Focused on essential clinical information
Shorter sentence structure
Removes conversational filler
Prioritizes actionable data

Example output:

S: 5yo FS Golden Retriever. Limping RH leg x3 days. No trauma witnessed. O: BCS 5/9. HR 100, RR 24. Mild pain on extension R stifle. No swelling. A: Possible cruciate injury P: Carprofen 75mg BID x7d. Recheck in 1 week. Radiographs if no improvement.

Best for:

High-volume general practice
Quick documentation needs
Technician visits
Routine preventive care

Detailed

Characteristics:

Comprehensive clinical narrative
Complete sentence structure
Includes contextual information
Thorough differential discussions

Example output:

Subjective: Bella is a 5-year-old female spayed Golden Retriever presenting for evaluation of right hind limb lameness of 3 days duration. Owner reports sudden onset, no witnessed trauma. Dog is reluctant to bear full weight on the affected limb. Objective: Patient is bright, alert, and responsive. Body condition score 5/9. Heart rate 100 bpm, respiratory rate 24 bpm. Orthopedic examination reveals mild pain on cranial drawer test of the right stifle with no obvious instability. No joint swelling or crepitus appreciated. Assessment: Differential diagnoses include partial cranial cruciate ligament tear, meniscal injury, or soft tissue strain. Clinical signs and examination findings are most consistent with early cruciate disease. Plan: Initiated medical management with carprofen 75mg PO BID for 7 days to reduce inflammation and pain. Client instructed on strict rest and leash walks only. Recheck examination scheduled in 1 week. If lameness persists or worsens, will proceed with sedated orthopedic examination and radiographs to further characterize the injury.

Best for:

Specialty/referral practices
Complex medical cases
Surgical procedures
Legal documentation needs

You can toggle between detail levels in the template preview to see how each setting affects AI output structure. The recommended level is indicated with a badge.

Template Structure

Sections

Each template contains multiple sections (e.g., Subjective, Objective, Assessment, Plan):

interface TemplateSection {
  id: string;
  name: string;          // "Subjective", "Objective", etc.
  fields: TemplateField[];
  order: number;         // Display sequence
}

Fields

Within each section, individual fields define specific data points:

interface TemplateField {
  id: string;
  name: string;          // "Chief Complaint", "Heart Rate", etc.
  type: 'text' | 'number' | 'date' | 'select' | 'checkbox' | 'textarea';
  required: boolean;     // Must be populated
  options?: string[];    // For select/dropdown fields
  defaultValue?: string;
  section?: string;
  order: number;
}

Field Types

Type: textSingle-line text entryUse for:

Pet name
Owner name
Medication names
Short descriptions

Type: numberNumeric values with optional validationUse for:

Weight (kg or lbs)
Heart rate (bpm)
Temperature (°F)
Dosages

Type: dateCalendar selection for date valuesUse for:

Visit date
Last vaccination date
Follow-up appointment date
Surgery date

Type: selectPredefined options listExample options:

Triage level: [“Routine”, “Urgent”, “Emergency”]
Body condition score: [“1/9”, “2/9”, …, “9/9”]
Dental grade: [“0”, “1”, “2”, “3”, “4”]

{
  name: "Body Condition Score",
  type: "select",
  options: ["1/9", "2/9", "3/9", "4/9", "5/9", "6/9", "7/9", "8/9", "9/9"]
}

Type: checkboxBoolean true/false fieldsUse for:

Neutered status
Microchipped
Current on vaccinations
Owner declined treatment

Type: textareaMulti-line text entryUse for:

Chief complaint narrative
Physical exam findings
Treatment plan details
Client instructions

Built-In vs. Custom Templates

Built-In Templates
Custom Templates

Characteristics

Pre-configured by Paw & Care system
Labeled “Built-in” in template list
Cannot be deleted
Can be copied to create custom variants
Updated with system releases

Modification

Built-in templates cannot be directly edited, but you can:

Select the template
Click “Copy and customize”
Modify the copy as needed
Set the custom version as your default

System updates may change built-in templates. If you rely on specific field structure, create a custom copy to preserve your preferred format.

Default Template

The template marked as default is automatically used for:

AI-generated SOAP notes from appointments
Quick documentation entry
Voice dictation transcription

Setting a Default

Select desired template from list
Click “Make default” button in preview header
Star badge appears next to template name
Previous default is unmarked

Only one template can be default at a time.

Template Field Display

The preview panel shows all fields for the selected template:

<div className="flex items-center gap-2 py-2 px-4 rounded hover:bg-muted/50">
  <span className="text-sm text-muted-foreground">{field.name}</span>
  {field.required && (
    <span className="text-red-500 text-xs">*</span>
  )}
  {field.type === 'select' && field.options && (
    <Badge variant="outline" className="text-[10px] ml-auto">
      {field.options.length} options
    </Badge>
  )}
</div>

Display elements:

Field name in muted text
Red asterisk (*) if required
Badge showing number of dropdown options (for select fields)
Hover effect for visual feedback

Best Practices

Choosing the Right Detail Level

Use Concise when:

Seeing 20+ patients per day
Most visits are routine/preventive
Documentation time is a bottleneck
Notes are primarily for internal use

Use Detailed when:

Handling complex medical cases
Generating referral documentation
Legal/insurance scrutiny is common
Comprehensive client handouts are needed
Specialty practice with lower volume

Customizing Templates Effectively

Start with built-in: Copy an existing template rather than building from scratch
Mark required fields thoughtfully: Too many required fields slow documentation
Use dropdowns for standardization: Select fields ensure consistent terminology
Test with AI generation: Generate sample notes to verify field structure
Get team input: Veterinarians and technicians should approve template changes
Version control: Keep notes about why changes were made and when

Managing Multiple Templates

Limit total count: 5-10 templates covers most practice needs
Clear naming: Use descriptive titles (“SOAP - Orthopedic” not “Template 3”)
Distinct purposes: Each template should serve a specific use case
Regular review: Quarterly audit to remove unused templates
Staff training: Ensure team knows which template to use when

Required Field Strategy

Always require:

Patient identification (name, ID)
Date of visit
Veterinarian name

Consider requiring:

Chief complaint/reason for visit
Physical exam findings
Assessment/diagnosis
Treatment plan

Rarely require:

Optional lab values
Follow-up instructions (if not needed)
Client education notes
Detailed differential diagnoses

Copy and Customize Workflow

Select source template

Click any template in the list to view its structure

Click 'Copy and customize'

Button located in template preview header

Modify template properties

Update title, description, detail level as needed

Adjust fields

Add new fields
Remove unnecessary fields
Change field types or options
Reorder fields within sections

Save custom template

Template appears in list without “Built-in” label

Set as default (optional)

Make your custom template the practice standard

Template Data Model

Reference data structure for custom integrations:

export type TemplateType = 
  | 'soap' 
  | 'soap_specialist' 
  | 'formatted_dictation' 
  | 'dental_canine' 
  | 'dental_feline' 
  | 'radiograph' 
  | 'callback' 
  | 'tech_appointment' 
  | 'surgery_report' 
  | 'staff_meeting' 
  | 'rounds' 
  | 'lecture_note' 
  | 'custom';

export type DetailLevel = 'concise' | 'detailed';

export interface SOAPTemplate {
  id: string;
  title: string;
  type: TemplateType;
  description: string;
  detailLevel: DetailLevel;
  isDefault: boolean;
  isBuiltIn: boolean;
  sections: TemplateSection[];
  createdAt: string;
  updatedAt: string;
}

SOAP Notes

How to generate and edit clinical documentation using templates

AI Assistant

AI-powered note generation from voice dictation

Billing

How billing invoices are extracted from templated SOAP notes

Custom Fields

Advanced field customization and data validation

Get Started

Core Features

Practice Management

Mobile App

Administration

​Overview

​Template Library

SOAP - General

SOAP - Specialist

Dental - Canine

Dental - Feline

Radiograph Report

Surgery Report

​Additional Template Types

​Template Interface

​List Components

​Empty State

​Preview Components

​Detail Levels

Concise

Detailed

​Template Structure

​Sections

​Fields

​Field Types

​Built-In vs. Custom Templates

​Characteristics

​Modification

​Creating Custom Templates

​Editing Custom Templates

​Default Template

​Setting a Default

​Template Field Display

​Best Practices

​Copy and Customize Workflow

​Template Data Model

​Related Documentation

SOAP Notes

AI Assistant

Billing

Custom Fields

Build docs developers (and LLMs) love

Overview

Template Library

Additional Template Types

Template Interface

List Components

Empty State

Preview Components

Detail Levels

Template Structure

Sections

Fields

Field Types

Built-In vs. Custom Templates

Characteristics

Modification

Creating Custom Templates

Editing Custom Templates

Default Template

Setting a Default

Template Field Display

Best Practices

Copy and Customize Workflow

Template Data Model

Related Documentation