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Voice-to-SOAP Clinical Documentation
Patient:
John Smith
DOB:
03/15/1968
Visit:
Follow-up
Provider:
Dr. Sarah Chen
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Raw Transcript
Patient presents with chief complaint of persistent lower back pain for three weeks. Pain rated 6 out of 10, worse with prolonged sitting. No radiation down the legs. Denies numbness or tingling. Vitals: BP 128 over 82, pulse 74, temp 98.6. On exam, lumbar spine shows mild tenderness at L4-L5. Straight leg raise negative bilaterally. Assessment: Mechanical low back pain. Plan: Start naproxen 500mg twice daily, refer to physical therapy, follow up in 4 weeks.
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