SOAP Notes in South Africa: HPCSA Booklet 9 Guide, Templates and AI Documentation

In South Africa, a SOAP note should include the Subjective history, Objective findings, Assessment and Plan, and be dated, signed and kept for at least six years under HPCSA Booklet 9. HeroMed's AI Scribe drafts the SOAP note during the consultation, keeps it in the patient record, and turns the signed note into the invoice and scheme claim in one click.

HeroMed is South African practice software with an AI Scribe built in. For South African clinicians, it drafts the SOAP note during the session, keeps it in the patient record, and turns the signed note into documents, the invoice and the scheme claim.

The SOAP structure

Example note

This is a made-up example for illustration, not a real patient.

S: 42-year-old patient, three days of lower back pain after lifting boxes. Pain 6/10, worse when bending. No numbness or bladder changes. O: Reduced lumbar flexion, tender right paraspinals, neurological screen normal. A: Acute mechanical lower back pain, no red flags. P: Advice on activity and posture, home exercises, review in one week or sooner if symptoms change.

Specialty guides

Each specialty records sessions a little differently. Our specialty guides use the same layout:

• Physio and physiotherapy SOAP notes
• Psychology and counselling progress notes
• Chiro and chiropractic SOAP notes
• OT (occupational therapy) notes and reports
• Biokinetics assessment and progress notes
• GP and family medicine SOAP notes and referrals
• Speech therapy and speech-language therapy notes
• Audiology reports and hearing assessment notes
• Dietetics ADIME and nutrition notes
• Podiatry SOAP notes and foot assessments
• Lactation consultant and private midwife notes

HPCSA Booklet 9 and POPIA: record-keeping for South African clinicians

The HPCSA's Guidelines on the Keeping of Patient Health Records (Booklet 9, revised September 2022) apply to every registered practitioner. In plain terms:

• What a record must contain (section 3.2). The patient's identifying details, a full history including allergies, the time, date and place of each consultation, your assessment, the proposed management, medication and dosage, referrals, the patient's response to treatment, investigations and results, time booked off work and why, and written proof of informed consent where relevant.
• Write it at the time (section 4.1). Notes are made during or as soon as possible after each interaction. Late entries are marked as late, with the reason.
• Make it clear and attributable (sections 4.2 and 4.3). Records must be accurate, legible and free of unclear abbreviations, and every entry must show who made it. Allergies and special needs should be easy to see (section 4.4).
• Changes are recorded, not hidden (section 5). Late and extra entries are dated and signed (electronically for digital records), and the reason for any change or correction is written on the record. Records may not be tampered with.
• Keep it secure (section 6). Only authorised people may access records, whether on paper or electronic.
• How long to keep it (section 7). At least six years from the patient's last treatment. For patients treated as minors, at least until their 21st birthday. For mentally incapacitated patients, for their lifetime. Records under the Occupational Health and Safety Act, 20 years after treatment.
• Patient access (section 9). Anyone aged 12 or older may ask for a copy of their own records. For a patient under 16, a parent or guardian may apply, but access needs the patient's written authorisation.

Under POPIA, health information is special personal information. You need a lawful reason to process it, consent where it applies, reasonable security (passwords, user permissions, backups) and a way to report breaches.

HeroMed keeps every signed note in the patient record with a date, an author and a history of changes, and access is controlled per user. This is general guidance, not legal advice. Read the official Booklet 9 on the HPCSA site and speak to your professional body if you're unsure.

From note to invoice in HeroMed

1. Patient snapshot. Before the patient sits down, HeroMed's AI summarises their history from the record, so you start the session already knowing what happened last time.
2. AI Scribe drafts the note. With the patient's consent, the AI Scribe listens to the session and drafts the note in the structure above, using a built-in template or one you set up for your practice. You review, edit and sign.
3. Documents and Ask AI. From the signed note you can generate referral letters, reports and sick notes, and ask the AI questions about the patient's notes.
4. One-click billing. The signed note prepares the invoice and the medical scheme claim in one click, with no copying into another system.

For South African clinicians, that means the note you sign is also the start of your billing, your letters and your next booking.

Checklist before you sign a note

• Date, time and your name are on the note
• Patient's own words are recorded where they matter
• Findings are measurable and comparable with last time
• Assessment explains your reasoning
• Plan includes follow-up and any referral
• Consent is recorded where needed
• You reviewed the AI draft before signing

Related reading

• What does HeroMed's AI Scribe do?
• Standalone AI scribe vs integrated practice management
• HeroMed AI Scribe