AI SOAP notes for veterinarians · Early access
The SOAP note that thinks.
Paste your exam notes. About a minute later you have a SOAP with ranked differentials and a tiered plan, a list of what wasn't documented, a client letter, and a recheck plan. You read it, fix what you disagree with, and copy it into your PIMS.
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Sol — 1y MN mixed breed. Adopted Dec '25 from shelter, dewormed there. Chronic intermittent diarrhea since before adoption. Fecal score 4–7, mucus, tenesmus, urgency (wakes O at night), very foul, occ frank blood. Lots of episodes past month. Clear from May to late July — longest stretch yet. No known trigger, no diet change / indiscretion / stress. Fecals neg since adoption. GI panel 8/26 WNL except TLI slightly low. Occ regurg/reflux since ulnar ostectomy 5/1 — spacing out. Occ vomiting. Aug: acute urinary + fecal incontinence, anal sphincter open, formed stool while lying down. Resolved, cause unknown. Eating/drinking normal, BAR, no wt loss, no V/C/S. Meds: gabapentin 100 mg 2–3 caps q8–12h, trazodone 50 mg q8–12h, Numelvi 1 tab, Duralactin, FortiFlora, Simparica Trio. Prev Clavamox, carprofen, ondansetron. Diet: Purina EN, 3 c/day. PE: mild L fore lameness, o/w NSF.
Chronic intermittent large-bowel–predominant diarrhea since before adoption (12/2025); relapse over the past month after remission 5–7/2026. Mucus, tenesmus, urgency, intermittent hematochezia; fecal score 4–7. Intermittent regurgitation since 5/2026, improving. Transient urinary and fecal incontinence 8/2026, resolved. Appetite, energy, and weight stable.
Mild L forelimb lameness s/p ulnar ostectomy + ESF (5/1/26); remainder of exam unremarkable.
- Not documented: rectal exam. Indicated for hematochezia and tenesmus.
- Not documented: sacral neuro exam. Indicated after the incontinence episode.
- Not documented: weight, BCS, T/P/R.
Low-risk chronic enteropathy in a systemically well one-year-old. Work the common causes first, one variable at a time.
Problem 1 · chronic LB diarrhea with hematochezia · differentials, ranked
- Food-responsive enteropathy concurrent pruritus (on a JAK inhibitor); EN is not an elimination diet
- Occult Trichuris / Giardia shelter origin; Simparica Trio has no whipworm claim
- Fiber-responsive colitis
- Dysbiosis remission overlapped the Clavamox course
- Partial EPI TLI equivocal: fasted recheck in 4 wk
- Drug-associated ilunocitinib GI effects; labeled ≥12 mo, confirm age at start
- Chronic inflammatory enteropathy
- Hypoadrenocorticism would also explain the regurgitation
+ 6 further problems: equivocal TLI · regurgitation · transient incontinence · lameness · presumptive allergic dermatitis · polypharmacy
Tier 1 · today
Pooled ZnSO₄ flotation + Giardia Ag + fecal antigen panel · CBC, chemistry, electrolytes · baseline cortisol · UA + culture · rDVM GI panel values · fasted TLI recheck at 4 wk.
Treatment · one change at a time
- Fenbendazole 50 mg/kg PO q24h × 5 d; repeat at 3 wk and 3 mo. Switch to a whipworm-labeled preventive.
- Hydrolyzed diet trial × 4 wk. Stop Duralactin and FortiFlora. Add psyllium at 2 wk if partial response.
- Cobalamin if <400 ng/L. Enzymes only if TLI confirms EPI.
- Taper gabapentin/trazodone if comfortable. Review Numelvi timing with the prescriber.
Recheck 2–3 wk with fecal log and weight · escalate to US / biopsy on weight loss, hypoalbuminemia, or melena
Dear [Owner's name],
Thank you for bringing Sol in today. I know the middle-of-the-night trips outside have been exhausting, so here is what we found and what to do at home.
What we found
Sol's exam was reassuring. He is eating well, holding his weight, and full of energy. Those are the most important signs that his gut problem, while frustrating, is not dangerous. The pattern of his diarrhea tells us most of the irritation is in his large intestine. In a dog his age that is most often parasites that hide from routine tests, a food sensitivity, or a gut that needs more fiber, and we are working through those first.
Two things stood out. Sol's monthly Simparica Trio does not protect against whipworms, and Purina EN, while easy to digest, is not designed to rule out a food sensitivity, so he has not yet had a true food trial. We are addressing both.
Medications and home care
- Fenbendazole: ___ with food once daily for 5 days, starting tonight. We'll repeat it in 3 weeks and 3 months.
- Food trial, starting the day after the dewormer: switch to [hydrolyzed diet] over 5 days, then only this food for at least 4 weeks. No treats, chews, or pill pockets. Use the new kibble as treats. Pause Duralactin and FortiFlora.
- Give pills with a few kibbles and a drink of water afterward.
- Score each stool on the chart provided and note blood, mucus, and night-time trips.
When to call us right away
- Vomiting more than once or twice in a day
- Dark, tarry stool or large amounts of blood
- Not eating, unusual tiredness, or weight loss
- Leaking urine or stool again, or wobbly back legs
Continues: other medications · reflux · the pancreas result · next steps
- Day 1–5Fenbendazole course. Pooled 3-day stool sample dropped off day 3.
- Day 6–10Transition to hydrolyzed diet. Duralactin and FortiFlora paused.
- Day 7Phone check-in. Lab results reviewed with owner; taper plan for gabapentin/trazodone if comfortable.
- Week 2–3Recheck exam with fecal log and weight. Add psyllium if partial response.
- Week 3Fenbendazole, second course.
- Week 4Fasted TLI recheck (12-hour fast, water fine). Cobalamin decision.
- Week 8–12Dermatologic read on the diet trial. Preventive switched to whipworm-labeled product.
- Month 3Fenbendazole, third course.
Drafted from a real case with the owner's details removed. Signalment drafts. The examining veterinarian decides.
What it drafts
The parts a scribe leaves to you.
None of these were in Sol's notes. All of them were in his case.
Ranked differentials
Ordered, with the reason for the order.
Each problem gets a differential list ranked for this patient, with a short reason beside each entry. Food-responsive enteropathy sits first for Sol because he has concurrent pruritus and has never had a true elimination diet. Change whatever you disagree with.
Gap check
What the notes don't say.
Signalment compares what was documented with what the presenting problem calls for. Sol's notes had no rectal exam, no sacral neuro exam after the incontinence episode, and a preventive with no whipworm claim.
Client letter and recheck plan
The plan, written for the owner.
The plan becomes a discharge letter in plain language: what we found, what to give, when to call. The recheck plan lays the same steps out by date, so the next visit starts where this one ended.
Early access
You're still the doctor.
Signalment drafts. You read it, change what you disagree with, and sign. Nothing goes into a record unless you put it there.
Doses and label claims are the model's draft and are not yet checked against a formulary table. Check them against yours before they leave the page.
How it works
Three steps, about a minute.
Paste your notes
Typed shorthand or an export from your PIMS. Terse is fine: signalment, complaint, history, meds, diet, exam findings, any labs.
Signalment drafts
The SOAP, the client letter, and the recheck plan stream in as they are written. About a minute for a complex case.
Edit and copy
Fix anything, then copy plain text into your PIMS. Your drafts stay in your history so you can reopen them later.
Questions
What vets ask first.
Does Signalment replace my clinical judgment?
No. It drafts, you decide. Every differential and every flag comes with its reasoning, so you can disagree quickly. Nothing goes into a record unless you copy it there.
How does the gap check know what's missing?
It compares the documented history and exam against what the presenting problems call for: a rectal exam for hematochezia, a sacral neuro exam after incontinence, a fasted recheck for an equivocal TLI. Ignore any flag you disagree with.
Will it work with my PIMS?
Every section copies as plain text, so it works with any PIMS today. Direct integrations are not built yet.
Where do my notes go?
Your notes and drafts are stored under your account on AWS, encrypted, and only you can open them. We do not sell them. Email hello@signalment.ai and we will delete them.
Why "Signalment"?
It is the first line of every SOAP note: species, breed, age, and sex. It is also a word only veterinary medicine uses.
Early access
Try it on a real case.
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