Clinical documentation is not just about speed. It is about accuracy, structure, specialty context, and control. The best AI tools for SOAP notes and initial evaluations do more than transcribe visits. They help clinicians capture complex encounters, organize them correctly, and stay compliant without changing how care is delivered.
This is where OneChart stands apart.
OneChart is built to automate SOAP notes and initial evaluation documentation using AI, while keeping clinicians fully in control of structure, language, and final decisions.
Clean SOAP Notes, Every Time
SOAP notes only work when sections are clearly separated and consistently structured. OneChart generates notes with explicit Subjective, Objective, Assessment, and Plan sections, using templates selected before capture. This prevents section blending and keeps documentation aligned with clinical expectations and payer requirements.
Clinicians can review, edit, rename, and export notes before they ever leave the platform. The original transcript is preserved, so documentation always traces back to what was actually said during the visit map.
Designed for Specialty Language, Not Generic Summaries
AI documentation tools often break down when visits involve specialty terminology. OneChart is designed to recognize and structure language across multiple care settings, including:
- Physical Therapy and rehabilitation
- Sports medicine
- Mental health
- Primary care
- Home care and response teams
For PT and rehab workflows, templates support functional limitations, progress measures, goals, and home exercise content when included. The AI structures what is captured, but never invents diagnoses or clinical findings.
No Auto-Diagnosis, No Black Boxes
OneChart is positioned as a summarization and structuring system, not a diagnostic engine. It does not make autonomous medical decisions or infer diagnoses beyond what is captured during the encounter.
Clinicians remain responsible for verification, final assessment, and treatment decisions. This design choice reduces risk and aligns with how providers actually practice.
Multiple Ways to Capture a Visit
Clinical documentation does not happen in one format. OneChart supports several input methods so clinicians can work naturally:
- Live ambient listening during in-person or virtual visits
- Post-session dictation processed through the same AI engine
- Template-driven workflows selected before recording
- Hybrid capture, combining patient voice intake, clinician conversation, and document abstraction
There is no requirement for rigid phrasing. Natural conversation and free-form dictation are supported.
Built for Initial Evaluations, Not Just SOAP Notes
Initial evaluations are more complex than routine follow-ups. OneChart supports structured capture of:
- Past medical and surgical history
- Medication lists
- Functional complaints and limitations
- Assessment and plan sections generated from captured context
- Goal drafts through specialty or custom templates
Patient voice intake and document ingestion can contribute pre-visit context, helping clinicians start evaluations with relevant information already structured.
Custom Templates and Full Control
Every clinic documents differently. OneChart allows clinicians and organizations to create and manage custom templates across SOAP notes, consult notes, referral letters, and specialty formats.
Sections can be modified, excluded, or reordered. Payer-specific language and form-filling workflows can be incorporated through templates, rather than hardcoded logic.
Compliance-First by Design
OneChart is built with healthcare compliance in mind:
- HIPAA and PIPEDA alignment
- Encryption at rest and in transit
- Role-based access and supervisor review workflows
- Audit-friendly exports and documentation trails
AI suggestions, including billing codes, are presented with supporting evidence and confidence levels. Nothing is auto-submitted without clinician review.
Practical Output That Fits Existing Systems
Instead of forcing clinics to switch EMRs, OneChart works alongside existing systems. Notes can be copied, exported as PDF or text, emailed, or integrated through lightweight extensions and APIs, including workflows used by PT and rehab clinics.
This makes it easier to adopt AI documentation without disrupting established operations.
AI That Reduces Work Without Redefining Care
The best tools for automating SOAP notes and initial evaluations do not replace clinicians. They remove friction from documentation so providers can focus on care, not typing.
OneChart is built for that reality. It automates structure, preserves accuracy, supports specialty workflows, and keeps clinicians firmly in control of the chart.