Ambient SOAP Notes with Auto-Fill & Billing

We’re excited to introduce Ambient SOAP Notes, a major enhancement to clinical documentation in OpenEMR. This new feature streamlines note-taking, improves accuracy, and integrates billing suggestions directly into your workflow.

What’s New

Ambient SOAP (Live Documentation)

• Automatically captures and routes spoken or entered content into:
  • Subjective
  • Objective
  • Assessment
  • Plan
• Reduces manual typing and speeds up documentation

Auto-Fill from Dropdowns & Inputs

• SOAP notes now update dynamically as you:
  • Select dropdown values
  • Use chips and structured inputs
• Notes are generated in real time—no need to click “Generate”

Smart Billing Suggestions

• Automatically suggests:
  • ICD-10 codes (Assessment)
  • CPT codes (Plan)
• Based on:
  • Chief complaint
  • Clinical inputs
  • Selected specialty

Click-to-Accept Billing

• Billing codes appear as interactive chips
• Users can:
  • Review suggestions
  • Click to accept
  • Store codes for encounter billing

Workflow Improvements

• Fully reactive SOAP generation
• Reduced reliance on manual “Generate” buttons
• Seamless integration with existing encounter workflow
• Cleaner, more structured documentation

Built for Compliance

• No automatic billing submission
• Codes require user confirmation
• Maintains clear separation between:
  • Clinical documentation
  • Billing data

Who Benefits

• Providers: Faster documentation, less typing
• Front desk & billing: Cleaner data for claims
• Clinics: Improved efficiency and consistency