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Capability 05 • Documentation Automation

Compliant SOAP Notes Generated Seconds After the Call

Save 2.5 hours of pajama-time charting every day. DrGodly transforms ambient audio and pre-intake synthesis into fully compliant notes with ICD-10 and CPT codes aligned to your billing guidelines.

Ambient AI Scribe v5.2Generated in 8.4 seconds

Clinical SOAP Encounter Note

Encounter: Telehealth Consult #DG-7429 • Attending: Dr. Emily Vance, MD • Patient: Maya K.

Billable Codes:CPT: 99213 (Outpatient E/M)ICD-10: G44.209 (Tension Headache)ICD-10: I10 (Essential HTN)

SSubjective (HPI & Patient Report)

Ambient Transcribed

Maya K., a 38-year-old female with known history of mild essential hypertension on Lisinopril 10mg PO Daily, presents for evaluation of a 4-day history of bilateral retro-orbital headaches. Pain is characterized as dull and throbbing, rated 4/10 upon waking and escalating to 7/10 by late afternoon (~4:00 PM). Symptoms correlate with prolonged computer display work (10h/day) and work-related fatigue. Denies photophobia aura, nausea, vomiting, fever, or nuchal rigidity. No relief with OTC acetaminophen. Home blood pressure logged this morning was 122/78 mmHg.

OObjective (Vitals & Physical Exam Findings)

Verified In-Call

Vitals: BP 122/78 mmHg (seated, right arm), HR 68 bpm (regular sinus), Temp 98.4°F, SpO2 99% on room air, BMI 23.4. General: Well-nourished, alert and oriented x4 in no acute distress. HEENT: Normocephalic, atraumatic. Pupils equal, round, reactive to light (PERRL). Extraocular movements intact (EOMI) without nystagmus. Mild tenderness to bilateral trapezius and suboccipital musculature upon palpation. Neurological: Cranial nerves II-XII grossly intact. No focal motor or sensory deficits. Gait normal.

AAssessment (Clinical Diagnoses)

ICD-10 Cross-Checked

1. Tension-type headache, unspecified (ICD-10: G44.209) — Primary etiology, consistent with bilateral distribution, lack of migrainous features, and afternoon asthenopia. 2. Digital eye strain / asthenopia (ICD-10: H53.149) — Aggravating contributor secondary to prolonged screen exposure. 3. Essential (primary) hypertension (ICD-10: I10) — Stable, well-controlled on current ACE-inhibitor regimen.

PPlan & Orders (Interventions, Rx, Follow-Up)

Patient Summary Synced

1. Non-Pharmacologic / Ergonomics: Implement the 20-20-20 screen rule (every 20 minutes, look at an object 20 feet away for 20 seconds). Optimize monitor eye-level distance and consider blue-light filtration lenses. Hydration target: 2.5L daily. 2. Pharmacotherapy: Trial Naproxen 375mg PO BID with food PRN at early onset of afternoon headache (max 3 consecutive days to prevent medication-overuse headache). Avoid daily NSAID reliance. 3. Hypertension Maintenance: Continue Lisinopril 10mg PO once daily in morning. Maintain twice-weekly home BP log in DrGodly health vault. 4. Preventive Follow-Up: Schedule routine optometrist refraction examination to rule out uncorrected astigmatism. Return to clinic in 4 weeks or sooner if red-flag symptoms arise. CPT Code: 99213 (Office/Outpatient Established, Level 3 E/M).

Electronically signed: Dr. Emily Vance, MD (NPI: #1849204819) • Oct 24, 2024 at 10:32 AM

FHIR DocumentReference Validated