​

AI Scribe & Medical Notes Guide

Use artificial intelligence to create clinical notes automatically. Save time on documentation while maintaining comprehensive patient records.

​

Getting Started

Access the scribe feature by clicking Clinical > Scribe or Patient > Medical Notes & Data. Two main capabilities:

• AI Scribe - AI listens to appointments and creates notes
• Note Templates - Pre-formatted notes you customize quickly

​

AI Scribe Explained

The AI Scribe works by:

1. Recording the appointment (voice or video)
2. Transcribing what was said
3. Extracting key clinical information
4. Auto-generating medical note
5. You review and edit before saving

​

How It Works

During Appointment:

1. Open patient appointment
2. Click Start Scribe
3. AI listens to conversation
4. You provide care normally
5. Click Stop Scribe when done

After Appointment:

1. AI processes recording
2. Creates transcript
3. Generates draft note
4. Extracts:
   • Chief complaint
   • Assessment
   • Plan
   • Medications discussed
   • Follow-up instructions

You Review:

1. Read AI-generated note
2. Edit for accuracy
3. Add missing information
4. Correct any errors
5. Approve and save

​

Starting a Recording

Before Appointment:

1. Go to appointment in calendar
2. Click Create Note
3. Choose AI Scribe
4. Click Record
5. Device starts recording

During Appointment:

1. Speak naturally
2. No special equipment needed
3. Built-in microphone works
4. Can move around freely

After Appointment:

1. Click Stop Recording
2. System starts processing
3. Takes 5-15 minutes typically
4. Generates draft note
5. Sends notification when ready

​

Processing Time

Processing depends on:

• Appointment length
• Audio quality
• System load
• Speech clarity

Typical timeline:

• 30-minute appointment → 10 minutes processing
• 60-minute appointment → 15 minutes processing

You’ll receive notification when note is ready.

​

Reviewing AI-Generated Notes

​

Reading the Transcript

1. Go to Clinical > Scribe
2. Find appointment
3. Click View Transcript
4. Read full word-for-word transcript
5. Timestamps show when things were discussed
6. Search feature finds specific topics

Use transcript to:

• Review exactly what was said
• Find specific information
• Verify accuracy
• Support note creation

​

Editing the Note

AI creates draft note, you edit:

1. Click Edit Note
2. Make corrections to text
3. Add missing details provider forgot to mention
4. Remove irrelevant information
5. Add clinical assessments
6. Update medication list
7. Refine plan/next steps

What to look for:

• Drug names spelled correctly
• Dosages accurate
• Plan is clear and actionable
• No contradictions
• Professional tone
• Complete information

​

Before vs. After Photos

For cosmetic/aesthetic procedures:

1. Click Add Media
2. Upload before photos (taken before appointment)
3. Upload after photos (same day or follow-up)
4. AI identifies relevant images
5. Links to note automatically
6. Attaches to patient record

Photos useful for:

• Before/after documentation
• Treatment assessment
• Patient satisfaction
• Results tracking
• Insurance claims

​

Note Templates

Pre-formatted templates speed up documentation.

​

Using a Template

Instead of AI Scribe, use templates for faster entry:

1. Open patient
2. Click Create Note
3. Choose Template
4. Select template type:
   • Consultation
   • Follow-up Visit
   • Procedure Note
   • Assessment
   • Procedure Complication
5. Fields auto-populate
6. Fill in patient-specific information
7. Save

​

Template Sections

Templates typically include: Header:

• Patient name, DOB, MRN
• Date of visit
• Provider name
• Appointment type

Chief Complaint:

• Patient’s main concern
• Duration/onset

History of Present Illness:

• Detailed symptom description
• Relevant medical history
• What’s been tried
• Results

Physical Examination:

• Vital signs
• Examination findings
• Relevant observations

Assessment:

• Diagnosis or impression
• Brief reasoning

Plan:

• Treatment plan
• Medications prescribed
• Follow-up needed
• Patient education provided
• Next visit scheduled

​

Customizing Templates

Create your own template:

1. Go to Settings > Note Templates
2. Click Create Template
3. Name it (e.g., “Botox Consultation”)
4. Add sections
5. Add standard text (auto-fills)
6. Add variable fields ()
7. Save

Variables auto-populate:

​

Viewing Notes

​

Patient Note Timeline

See all notes in order:

1. Open patient
2. Go to Medical Notes & Data
3. View all notes in timeline
4. Most recent at top
5. Filter by date range
6. Search for keywords

Each note shows:

• Date created
• Provider who created
• Note type
• First few lines of content

​

Reading a Full Note

1. Click note in timeline
2. Full note content displays
3. View photos/attachments
4. See medications prescribed
5. View plan/follow-up

​

Note Visibility

Control who sees notes:

• Private - Only you and patient
• Shared - All providers see it
• Practice - All staff can see

Set privacy when creating note.

​

Advanced Features

​

Voice Dictation

Type-free note creation:

1. Click Dictate Note
2. Speak into microphone
3. Your speech transcribed to text
4. Edit as needed
5. Save

Good for:

• Quick notes after appointment
• Hands-free entry while in clinic
• When keyboard not available

​

API Integration

Connect notes to external systems:

• Electronic health records (EHR)
• Accounting software
• Patient portals
• Insurance systems

Contact support to set up.

​

Handoff Notes

Create quick notes for handoff: Example: “Patient doing well post-op. No complications. Pain managed. Next visit Tuesday.”

1. Click Create Handoff Note
2. Quick 1-2 line summary
3. Used for staff communication
4. Different from full medical note

​

Best Practices

​

Recording Quality

Good Audio:

• Quiet environment
• Close to microphone
• Clear speech
• No background noise
• Slow and clear pronunciation

Poor Audio:

• Loud background noise
• Far from microphone
• Mumbling or unclear speech
• Overlapping conversations
• Results in transcription errors

Tip: Test recording in room before using for patient.

​

Note Completeness

Always Include:

• Chief complaint
• Relevant history
• Examination findings
• Assessment/diagnosis
• Treatment plan
• Medications
• Follow-up plan
• Patient education

Never Forget:

• Patient allergies
• Medication interactions
• Contraindications
• Safety warnings
• Consent obtained

​

Using AI Effectively

AI is Good At:

• Transcribing words
• Organizing information
• Creating structure
• Identifying key terms
• Suggesting sections

AI May Miss:

• Clinical judgment
• Subtle findings
• Differential diagnoses
• Nuanced patient history
• Risk assessments

Always:

• Review AI output
• Make corrections
• Add clinical thinking
• Don’t trust AI implicitly
• Verify accuracy

​

Documentation Standards

Legal Requirements:

• Legible and clear
• Dated and signed
• Complete and accurate
• Timely (within 24 hours typical)
• Protected from unauthorized access

Best Practices:

• Use objective language
• Document what you observed (not assumptions)
• Include patient education given
• Include patient response to treatment
• Note any complications
• Document informed consent obtained

​

Protecting Patient Privacy

Security:

• Records encrypted
• Only authorized staff access
• Audit trail of who accessed note
• Secure storage
• HIPAA compliant

Never:

• Leave notes visible on screens
• Discuss patients where overheard
• Share notes with unauthorized people
• Email notes insecurely
• Print and leave unattended

​

Troubleshooting

“Recording didn’t work”

• Check microphone is enabled
• Verify internet connection stable
• Try in quieter environment
• Reload page and try again
• Try different browser

“Transcription is inaccurate”

• Audio quality may be poor
• Background noise was present
• Speech too fast or unclear
• Accents or dialects may affect
• Edit manually or re-record

“AI missed important information”

• AI focused on main points
• Add missing info in edit
• Use templates for consistency
• AI learning from corrections
• Report errors to improve system

“Can’t find note I created”

• Check date range filter
• Search by keyword
• Check patient’s name spelling
• Verify correct patient selected
• Note may still be processing

​

Related Features

• Appointments - Create notes from appointments
• Patient Records - All notes in medical record
• Forms - Intake information before notes
• Gallery - Photos and attachments in notes
• Billing - Document services for charges
• Communications - Document patient conversations

​

Compliance & HIPAA

​

Documentation Audits

Regular audits ensure:

• Notes complete and accurate
• Timely completion
• Proper authentication
• No errors or omissions
• Legal defensibility

​

Retention Requirements

Keep notes:

• Minimum 3-7 years (varies by state)
• Some states require longer
• Consult legal/regulatory requirements
• Secure storage and backup
• Accessible if patient requests

​

Patient Access

Patients have right to:

• Request copy of notes
• Request corrections
• Know who accessed records
• Data privacy

Implement in Settings > Patient Portal. For advanced documentation features, speech recognition in multiple languages, or custom templates, contact your account manager.