How to Make AI SOAP Notes Sound More Human

Clinicians tell us they love the speed of AI‑but not when the output reads like a robot. If your AI‑generated SOAP notes sound flat, generic, or misaligned with how you practice, this guide will help you tune them so they feel authentic, clinically complete, and easy to skim after a long day.

Tired of Robotic-Sounding AI SOAP Notes? Many Clinicians Are Too

If you’ve tried an AI scribe or note assistant, you’ve likely seen the time savings‑and the occasional awkward phrasing. Recent studies on ambient AI documentation show meaningful gains in efficiency and reduced mental burden for clinicians, even as editing and style concerns remain.

At the same time, language choices in clinical notes are not trivial. As Goddu et al. put it, “Stigmatizing language used in medical records to describe patients can influence subsequent physicians‑in‑training.”

And for physical therapy and other specialties, strong documentation underpins risk management, continuity, and communication across teams. APTA’s defensible documentation resources emphasize clear elements for each encounter and episode‑of‑care summaries.

Why Personalization Matters in AI-Generated SOAP Notes

Preserve Authenticity and Clinical Intent

SOAP notes are more than a format, they capture your reasoning. As StatPearls notes, “The SOAP note is a way for healthcare workers to document in a structured and organized way.” That structure should still reflect your voice, therapeutic approach, and the patient’s own words where appropriate.

Reduce Time Spent Rephrasing or Editing Notes

When your style cues are built into the prompt and template, you spend less time fixing tone and more time verifying facts. In quality‑improvement studies, ambient documentation platforms were associated with decreased time in notes per appointment and improved satisfaction, benefits that grow when editing is “right‑sized.”

Improve Patient‑Clinician Continuity

Consistency across clinical notes helps colleagues ‑ and your future self ‑ understand patient progress and next steps at a glance. APTA underscores documentation across the episode of care (initial evaluation, visit, re‑examination, discharge summary), a model that benefits from a stable writing style.

Real Examples: Robotic vs. Humanized AI SOAP Notes

Below are short, anonymized examples showing how a small change in instructions can transform the tone of SOAP notes without sacrificing accuracy.

Example 1 - Outpatient Therapy Sessions (Mental Health)

Robotic
S: Patient states mood is “fine.” Denies SI/HI. Reports sleeping 6 hours.
O: Affect restricted. Eye contact reduced. PHQ‑9 score 10.
A: Moderate depressive symptoms. Limited coping skills.
P: Continue CBT. Assign homework. Follow up in 2 weeks.

Humanized
S: Patient described the week as “up‑and‑down,” noting improved mornings and low energy after work. Denies safety concerns. Slept ~6 hours per night.
O: Affect somewhat constricted early in the session, warming with rapport; PHQ‑9 = 10 today.
A: Persistent moderate depressive symptoms with emerging morning momentum; practicing cognitive restructuring with partial success.
P: Continue CBT with emphasis on thought records tied to post‑work fatigue; review sleep schedule; share coping plan with partner; follow up in 2 weeks.

Tip: Keep the patient’s phrasing in S when clinically appropriate; summarize patterns in A; make P specific enough that another clinician could continue care seamlessly. For more on related documentation, see our guide to Progress notes.

Example 2 - Physical Therapy Visit (Knee OA)

Robotic
S: Reports pain 5/10. Pain worse with stairs.
O: Knee flexion 115°. Quad strength 4/5. Antalgic gait.
A: Knee OA with decreased ROM and strength.
P: HEP for quad/hip, 2x/week x 6 weeks.

Humanized
S: Patient reports “stair pain” peaking at 5/10 by day’s end; morning stiffness improves after a short walk.
O: Knee flexion 115°; quad 4/5; antalgic gait reduces with cueing; tolerates 10 sit‑to‑stands without flare.
A: Findings consistent with knee OA; function limited mainly by eccentric control on descent and endurance late in the day.
P: Progress HEP to include eccentric step‑downs and hip abductor work; add short daily walk before stairs; trial kinesiology tape for activity days; reassess tolerance in 1 week.

For a deeper dive into structure, see our walkthrough on how to write SOAP notes and grab a reusable SOAP note template.

How to Train AI Tools to Sound More Human: Best Practices

1. Write Structured and Detailed Prompts

Tell the model exactly what to produce. Specify the discipline, setting, and your preferred tone. Include the patient goal and what not to do (e.g., avoid stigmatizing labels).

2. Create Reusable Templates That Reflect Your Style

A lightweight template plus a few examples of “before/after” phrasing will steer outputs toward your voice. Store separate templates for mental health therapy sessions and physical therapy so the model uses the right verbs and metrics by default.

3. Add Clear Instructions for Formatting and Tone

Call out reading level, bullet vs. paragraph preferences, and whether you want brief rationales in A. Consider adding a one‑line glossary (e.g., “use ‘person living with diabetes,’ not ‘diabetic’”).

4. Stick to One Tool and Refine Your Templates

Switching between different AI tools resets their quirks. You’ll get more consistent SOAP notes by investing in one platform and iterating on your prompts.

5. Provide Feedback to the Model During Use

Inline feedback works: “Rephrase the Assessment to highlight patterns across the last 3 visits,” or “Tighten the Plan to three bullets with exercises + dosage.” Over a week or two, this trims editing time.

6. Regularly Review and Update Style Prompts

Refresh your template when your clinic’s language norms evolve (e.g., updates from AMA/APA on inclusive, bias‑free language) or when your own preferences change. Keep a changelog so colleagues can align quickly.

How to Review and Edit AI-Generated SOAP Notes

Scan for Accuracy and Clinical Completeness

• Numbers: vitals, dosages, test scores, and ranges.
• Attribution: note what came from the patient vs. your observations.
• MDM linkage: in A, ensure findings explain your differential/plan; in rehab, tie impairments to function and patient goals.
• Continuity: each entry should make the next one easier to write.

Check Alignment with Your Therapeutic Approach

Do the A and P reflect your modality? For mental health professionals using CBT vs. ACT, or for physical therapy plans emphasizing motor control vs. tissue loading, the verbs and rationales should match.

Tweak Language for Personalization and Nuance

• Use person‑first language and avoid judgment (“person living with AUD,” not “alcoholic”).
• Preserve patient phrases in S when clinically informative.
• Replace generic phrases (“patient educated”) with specifics (“reviewed pain pacing; practiced 2‑minute rest breaks on stairs”).
• Keep plans measurable so patient progress can be tracked over time.

AI-Generated Language Quick Swaps (Examples)

Quick Style Checklist (Pin This)

• Keep S concrete: one or two quotes that capture the week.
• In O, list only the measurements that changed management.
• In A, connect findings to function and diagnosis; call out trends across visits.
• In P, make next steps measurable so patient progress is easy to verify.
• Prefer person‑first language; avoid shorthand that can stigmatize.
• Keep paragraphs short so busy teams can scan clinical notes while delivering patient care.

Discipline‑Tailored Prompt Snippets

For mental health professionals (outpatient):

Use CBT/ACT language as applicable. In S, capture 1–2 verbatim phrases. In A, summarize patterns (triggers, cognitive themes) and tie them to goals. In P, include homework and safety steps if relevant.

For physical therapists (orthopedics/sports):

State functional baselines and irritability. In A, link impairments to function (e.g., "eccentric control limits stair descent"). In P, include dosage (sets/reps/tempo), progression criteria, and return‑to‑activity guidance.

These patterns help AI tools echo your discipline’s priorities without bloating the note.

Notes that Matter in Your Setting

For mental health professionals

• When sessions are intense, jot two anchor details immediately after therapy sessions so the AI has authentic material to work with later.
• If you keep separate psychotherapy notes, ensure your clinical notes omit sensitive detail while still supporting billing and coordination of patient care.

For physical therapists

• Standardize common phrasing for load, tempo, and range to make your medical documentation consistent across the team.
• Ask for short rationales in A (“why this exercise now?”) so another PT can safely advance the plan of care and improve patient care on day one.

Common Challenges in AI-Generated SOAP Notes

Inconsistent AI Tone Across Sessions

Why it happens: small prompt changes, switching tools, or missing examples.
Fix: keep a single source‑of‑truth template; add a short “style sheet” with preferred phrases and verbs.

Loss of Nuance in Clinical Observations

Why it happens: rushed inputs or auto‑summaries trimming detail.
Fix: feed key quotes/metrics directly; ask the model to surface patterns across the last 2–3 visits in A.

Overreliance on Generic Phrasing

Why it matters: generic clinical notes hide what’s unique about your encounter and slow colleagues who need context.
Fix: require “show‑your‑work” in A (brief rationale), and require concrete actions/parameters in P.

Privacy and Ethical Concerns with PHI

HIPAA allows two de‑identification methods: Expert Determination or Safe Harbor (the latter is the “removal of specified individual identifiers”). Whatever platform you use, confirm how PHI is handled and whether a Business Associate Agreement is in place.

How Twofold Helps You Craft Personalized SOAP Notes with AI

Twofold’s HIPAA‑compliant AI scribe is built to keep your voice intact while streamlining the documentation process for busy clinics.

• Custom style profiles: We learn your phrasing and preferred structure so your SOAP notes are consistent across therapy sessions and specialties.
• Templates that match your work: Out‑of‑the‑box templates for mental health and physical therapy, plus tools to tailor A and P to your approach.
• Safety first: PHI is handled according to HIPAA guidance, with clear controls for data retention and access.
• Edit‑friendly output: We summarize patterns across visits in A and make P action‑oriented so patient care carries forward smoothly.
• One platform, less friction: Fewer toggles between apps = more consistent clinical notes.

Explore how Twofold approaches AI SOAP notes, and if you’re new to SOAP structure, start with our SOAP note template.

Technical note: Under the hood, we apply modern natural language processing to structure free‑text into dependable, readable notes, without flattening your voice.

Conclusion

Human‑sounding AI SOAP notes don’t happen by accident. They come from better inputs (clear prompts, examples, and templates), steady tooling, and thoughtful edit, all anchored in patient‑centered language and clinical rigor. Start with one template, iterate for a week, and measure your editing time drop. Your future self‑ and your patients‑ will feel the difference.

For more on structure and use cases, see our guides to AI SOAP notes, how to write SOAP notes, and Progress notes.