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Documentation Index

Fetch the complete documentation index at: https://docs.decodahealth.com/llms.txt

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AI Scribe records audio during a patient encounter, transcribes it, and uses AI to fill in a structured clinical note based on a template you choose.
Running a video appointment? See Telehealth Visits — the scribe joins the Google Meet and records the call for you, no microphone needed.

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Create an AI Scribe Note

1

Start a new AI note

From the Notes page, click New Note and select AI Note. You can also start an AI note from inside a patient chart using the Medical Notes tab. If a patient is not already selected, search for and pick one.
2

Allow microphone access and pick a device

When prompted, allow your browser to use the microphone. If permission was denied earlier, a warning banner appears with steps to re-enable it from your browser settings.After granting permission, choose a microphone from the device picker. An input level meter shows your current volume so you can confirm the microphone is working before recording. You can change the microphone at any time during a recording from the recording mini-player (see below).
3

Pick a template

A template defines the questions the AI fills in and is required before you can generate the note. Click the Template picker, search by name, mark favorites with the star, and pick one. If you skip this step, the picker opens automatically when you click Generate AI Note.
4

Record the encounter

Click the play button to start recording. Speak naturally during the appointment — audio is captured and transcribed in real time. While recording you can:
  • Pause and resume later.
  • Switch to a different note mid-recording. Recording continues in the background using the recording mini-player.
  • Watch the live transcript appear in the Transcript tab.
5

Generate the note

Click the large Generate AI Note button. The transcription is finalized and sent to the AI, which fills in each template question based on the conversation. Generation takes a moment — you can navigate away and come back later. The page automatically opens the Note Template tab when answers are ready.
6

Review and edit

The Note Template tab shows the AI’s answers grouped by section (if the template has sections). Review every field and edit anything that needs correcting. The AI’s output is a starting point — always verify clinical accuracy before signing off.For Medication fields, the AI only fills in medications that exist in your clinic’s medication catalog. If a drug mentioned during the encounter isn’t in the catalog, it won’t appear in the field — add the medication in Settings > Medications first.
7

Save

Click Save to keep your edits. Unsaved changes are tracked, and you’ll be prompted if you try to leave the page with edits pending.
A patient can opt out of having their visits recorded by AI Scribe. When a patient is opted out, the AI Note option is unavailable for them and a message reads Patient has opted out of AI Scribe. Set this on the patient’s chart under the Settings tab. The AI Scribe Consent field has three values:
  • Not Set — no preference recorded (AI Scribe is available).
  • Opted In — the patient agreed.
  • Opted Out — AI Scribe is blocked for this patient.
Patients can also set their own preference: add a question to an intake form and map it to AI Scribe Consent, and the patient’s answer updates this field automatically.

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The Note Template Tab

The Note Template tab is the main view for writing and reviewing an AI note. Before generating, it shows a disabled preview of the template’s questions so you can confirm you picked the right one. After generating, the same layout becomes editable and is filled in with the AI’s answers. If the template uses sections, each section appears as a collapsible block you can expand or collapse. Otherwise, questions appear in a single list.

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Recording Mini-Player

While a recording is active, a draggable mini-player appears on screen. Move it anywhere on the page. It includes:
  • Timer — elapsed recording time.
  • Audio visualizer — live audio input level.
  • Pause / Resume — pause and resume without stopping the recording.
  • Stop — end the recording.
  • Microphone picker — switch the input device.
  • Generate Note — jump straight to note generation.
  • Go to note — return to the recording’s note page if you’ve navigated elsewhere.
The mini-player lets you move around the app while recording continues in the background.

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Ask AI to Refine the Note

After the note is generated, a chat box appears at the bottom of the Note Template tab. Use it to ask the AI to make changes — for example:
  • “Add a note about the patient’s allergy to penicillin”
  • “Change the dosage to 20mg twice daily”
  • “Expand the assessment section”
Type your instruction and press Enter (or click the send button). The AI creates a new revision of the note with your changes. Each chat creates a new version, so you can always go back to an earlier one from the version history.
Save before you chat. If you have unsaved edits when you send a chat message, you’ll get a warning to save first. Otherwise the AI’s revision could overwrite work you haven’t kept.
The chat box also appears on manual notes, so you can use AI to clean up or expand a note even if it wasn’t dictated.

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Suggestions Sidebar

If the suggestions sidebar is turned on for your organization, a Suggestions panel appears on the left of the note page. When you click into a text field, the panel shows saved Suggestions — common phrases, exam findings, or boilerplate — scoped to that template and question. Click a suggestion to insert it at your cursor. Use the chevron at the top to collapse or expand the panel.

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Regenerate with a Different Template

To restructure an AI note using a different template:
  1. Open the note and click the actions menu (three-dot icon) in the note toolbar.
  2. Select Change Template.
  3. Pick a new template from the list.
  4. The AI regenerates the note from the original transcript using the new template, creating a new revision.
Regenerating with a different template creates a new revision. Any manual edits on the current version do not carry over — the new version is generated fresh from the transcript.