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This section explains how Auraliti converts speech or uploaded text into structured healthcare documents using the latest large language models and strict scribe-style rules. It also summarises universal tips that apply to every template: what the AI includes, what it omits, and how to capture complete, accurate output in busy clinical settings.
What Information it Includes:
- List of all supported document types and ideal use-cases
- How the AI applies the ‘omit empty headings’ rule for clarity
- How to get the best results from dictation vs conversational audio
- How contradictions are handled between current transcript and history
- Privacy, security and data-handling practices
- Links to sample outputs for each template
How to improve
- Be explicit, not implied: say numbers, dates, doses, routes, frequencies, timeframes and statuses aloud; the model will not infer or calculate missing details.
- Use brief verbal cues where helpful: saying “Assessment … Plan …” or “Allergies …” can improve section placement, especially in long notes.
- Separate speculation from facts: if you ‘think aloud’, finish by stating the final decision so the document reflects the confirmed plan.
- Pause between topics: short pauses help the model segment sections and reduce cross-contamination of content.
- Spell uncommon terms: drug names, devices, batch/lot numbers, or rare eponyms—spell once to lock in accuracy.
For conversational input:
- Do a quick recap: at the end, summarise the key diagnosis/plan/follow-up in a few sentences to improve completeness.
- Anchor timing: prefer exact dates or “3 days ago” over vague phrases like “recently”.
- State units with values: mmHg, mg, mL, bpm, °C—leave nothing to guesswork.
- Name the follow-up: say the interval and mode of next review to ensure it appears in the plan.
Frequently Asked Questions
A complete consultation-and-procedure note for aesthetic injection treatments. It captures goals, assessment, consent, a precise injection log and post-care instructions. Designed for documentation, audit trails and follow-up planning. This template is informed by contemporary international consensus statements on aesthetic botulinum toxin practice and documentation.
What Information it Includes:
- Consultation context (date, provider, setting, chaperone if applicable)
- Patient goals, key concerns and prior aesthetic history
- Skin/facial assessment and Fitzpatrick type (if stated)
- Planned treatment (brand, dilution, target muscles, units)
- Consent and education documented verbatim
- Procedure details: prep, injection log, lot/expiry
- Immediate outcome and after-care instructions
- Follow-up timing and cautions
How to improve
- Call out units by site: e.g., “4 units each to L/R corrugator, 2 units procerus”.
- State brand, dilution and lot/expiry: say them slowly; spell lot codes when needed.
- Document consent explicitly: e.g., “Written consent obtained after risks and alternatives discussed”.
- Dictate after-care clearly: the note mirrors your exact post-procedure instructions.
For conversational input:
- Narrate technique in real time: identify muscle, depth, needle gauge and volume while injecting.
- Verbalise adverse events immediately: bruising, pain, vasovagal symptoms.
- Confirm goals and expectations: restate timing (e.g., event date) and desired effect duration.
Frequently Asked Questions
A single concise paragraph (≤10 sentences) covering the presenting complaint, key findings, impression, management and follow‑up—ideal for quick handovers or messaging.
What Information it Includes:
- Presenting complaint and short history
- Salient exam/lab/imaging findings
- Impression/assessment
- Treatment provided or planned
- Follow-up or next steps
How to improve
- Lead with the main problem: keep secondary issues brief or omitted.
- Speak exact values: vitals, labs and imaging findings in numbers where possible.
- Close with the plan: specify actions and timeframes (e.g., “review in 48 h”).
For conversational input:
- Mark your transitions: e.g., “Assessment… Plan… Next steps…” so the narrative flows logically.
- Use time anchors: “three-day history”, “last dose this morning” improves clarity.
Frequently Asked Questions
Structured note for psychological, career, marital or other counselling sessions. Captures presenting concerns, interventions, insights and next steps in a clear session summary.Aligns with HPCSA Ethical Guidelines for Psychologists (Booklet 2, 2016) and the APA Record-Keeping Guidelines.
What Information it Includes:
- Session details (type, modality, duration)
- Presenting concern in the client’s own words
- Mental-status style observations (if stated)
- Interventions and techniques used
- Recommendations, tasks and follow-up
How to improve
- Name your techniques: e.g., “We used behavioural activation and cognitive restructuring”.
- State impact: briefly note functional effects at work/school/home if discussed.
- Record homework: say tasks verbatim to ensure they appear under Recommendations.
For conversational input:
- Reflect and confirm: short summaries (“What I’m hearing is …”) improve accuracy.
- Flag risk content: suicidal or harm concerns should be verbalised explicitly if discussed.
Frequently Asked Questions
Concise inpatient progress note for ward or ICU reviews, focused on overnight events, objective data, assessment and the plan. Aligned with HPCSA patient record‑keeping expectations and the South African National Core Standards for Health Establishments.
What Information it Includes:
- Interval history / overnight events
- Latest vitals, labs or imaging
- Updated assessment / problem list
- Plan and orders
How to improve
- Time-stamp events: e.g., “02:00 – hypotensive episode, responded to fluids”.
- Trend where relevant: “Creatinine down from 2.1 → 1.8 mg/dL”.
- Be plan-specific: doses, routes, targets and review timing.
For conversational input:
- Read out new orders: so they populate correctly in the plan.
Frequently Asked Questions
First-day admission note capturing referral context, HPI, focused ROS, exam, initial investigations and management orders. Aligned with HPCSA patient record-keeping principles and NICE CG50 guidance on recognising and responding to clinical deterioration in hospital.
What Information it Includes:
- Admission context and referral handover
- Presenting complaint and HPI
- Relevant past history, meds, allergies, social
- Physical exam and initial investigations
- Provisional diagnoses and initial orders
How to improve
- State triage/acuity: helps justify level of care.
- Name STAT actions: e.g., “Fluids started, 1 L normal saline”.
- Record pending tests: mention what is still outstanding and why.
For conversational input:
- Verbalise risk scores: CURB‑65, Wells, NEWS2 if you use them.
Frequently Asked Questions
Summarises the admission from presentation to discharge: the course in hospital, procedures, complications, medications to take home and follow‑up arrangements. Aligned with HPCSA record‑keeping principles and NICE NG27 recommendations on safe transitions and discharge communication.
What Information it Includes:
- Admission and discharge details
- Presenting concerns and inpatient course
- Investigations and procedures
- Diagnoses and complications
- Medications (TTO) and future care plan
How to improve
- Flag medication changes: say “NEW”, “STOPPED”, or “CONTINUED”.
- Include follow‑up specifics: dates, locations and the purpose of each appointment.
- Mention pending results: name the test and state it’s pending if not back yet.
For conversational input:
- Confirm destination and supports: e.g., home with family, district nurse review.
Frequently Asked Questions
An in-depth, hierarchical report mirroring a full internal-medicine work‑up—ideal for new intakes or complex cases with multi-system concerns.
What Information it Includes:
- Source/referral and occupation
- Chief complaint and timeline
- Full medical/surgical/psycho‑social histories
- Structured Review of Systems
- Physical examination by system
- Clinical summary, differentials, plan and referrals
How to improve
- Signal major headings: saying “Past Medical History…” improves section accuracy.
- Attach dates and control status: e.g., “Type 2 diabetes, dx 2015, HbA1c 7.8%”.
- Drop redundancies: any heading without content is auto‑omitted.
For conversational input:
- Ask clarifiers aloud: medication doses, durations, earlier interventions and responses.
- Summarise the problem list: before dictating the plan.
Frequently Asked Questions
Bridges the 1st-visit report with the current encounter: reviews progress on the prior plan, updates findings, and sets a refreshed roadmap.
What Information it Includes:
- Summary of previous consultation
- Patient feedback on last plan and adherence
- Status of prior tests and actions
- Focused exam with comparisons
- Results reviewed today and new tests
- Working diagnoses and updated plan
- Next follow-up interval and safety‑net advice
How to improve
- Tick off last visit’s actions: completed, pending, or changed.
- Compare to baseline: quote prior and current values (e.g., BP 160/100 → 138/88).
- Be explicit about adherence and side‑effects: capture the patient’s actual experience.
For conversational input:
- Ask per plan element: “Did you collect the blood test?” “Any dizziness on higher dose?”
- Restate dose adjustments aloud: prevents missed changes.
Frequently Asked Questions
A streamlined ongoing note for third and subsequent visits. Focuses on interval change, monitoring active problems and adjusting the plan quickly.
What Information it Includes:
- One‑line recap of last note
- Interval events and adherence
- Targeted vitals/focused exam
- Results reviewed and new orders
- Active problem status (better/unchanged/worse)
- Rolling plan updates and next steps
How to improve
- Stay problem‑oriented: update each active issue rather than re-telling the whole story.
- Use objective change: quote numeric differences where possible.
- Keep plans tight: list only today’s adjustments and clear follow‑up triggers.
For conversational input:
- Confirm interval events: ER visits, medication lapses, flares.
- State plan changes explicitly: including doses, routes and review timing.
Frequently Asked Questions
A concise work‑excuse certificate aligned with South African requirements. Confirms assessment date(s), fitness for work, recommended absence period and follow‑up. Diagnoses are only included if explicit consent to disclose was stated. This template follows the HPCSA Ethical Rules (Rule 16) and the Basic Conditions of Employment Act Section 23 on proof of incapacity.
What Information it Includes:
- Salutation and purpose statement
- Patient details (only if explicitly provided)
- Professional fitness assessment without diagnosis unless consent is stated
- Recommended period of absence and follow‑up date (if stated)
- Clinician name/sign‑off details (if stated)
How to improve
- Speak dates clearly: start/end dates and whether inclusive; clarify partial days if relevant.
- Document consent before disclosing a diagnosis: otherwise use functional wording only.
- State functional limitations when relevant: e.g., “No heavy lifting for 72 hours”.
- Avoid clinical detail beyond purpose: keep certificates focused and factual.
For conversational input:
- Clarify job demands: safety‑critical tasks may require specific restrictions.
- Restate the exact dates aloud: prevents clerical errors in the certificate.
Frequently Asked Questions
A comprehensive, general-purpose medical note that captures presenting problems, history, exam, investigations, assessment and plan for typical outpatient encounters. Aligned with HPCSA expectations for clear, complete patient records.
What Information it Includes:
- Chief concern and HPI
- Relevant past medical/surgical history
- Medications and allergies
- Family/social history (if stated)
- Physical examination and investigations
- Assessment and plan
How to improve
- Be condition‑specific: e.g., “RLQ tenderness 8/10 on palpation”.
- State negative findings only if voiced: avoid blanket negatives not discussed.
- Give exact doses and frequencies: the AI won’t infer missing drug details.
For conversational input:
- Restate key negatives you want included: e.g., “No fever, no vomiting”.
Frequently Asked Questions
A factual account of circumstances of death, clinical course, cause of death, interventions and communication—suited for internal audit, family updates or coronial documentation. Aligned with WHO guidance on medical certification of cause of death (ICD framework and international certificate format).
What Information it Includes:
- Circumstances and time of death
- Antecedent clinical course
- Diagnoses and cause of death
- Resuscitation and interventions
- Family communication and certification details
How to improve
- Keep a strict timeline: narrate events sequentially.
- Use official terms: e.g., immediate vs antecedent vs underlying cause.
- Document pronouncement details: who, where and when, if stated.
For conversational input:
- State times clearly: admission, deterioration and pronouncement times improve accuracy.
Frequently Asked Questions
A comprehensive neuropsychological assessment aligned with HPCSA standards and AACN guidance. Captures interview, behavioural observations, validity findings, test results by domain, integration, and recommendations—recording only what you explicitly state. This template reflects the AACN Practice Guidelines for Neuropsychological Assessment and Consultation and subsequent consensus statements on validity assessment.
What Information it Includes:
- Identifying information and evaluation context
- Reason for referral
- Interview and relevant background
- Behavioural observations and clinical impressions
- Validity (PVT/SVT) and interpretability (if stated)
- Test results by domain with scores (if provided)
- Psychological/personality measures (if used)
- Integrated summary, impressions and recommendations
- References (if cited) and person completing record
How to improve
- Dictate exact numbers: test names/editions, raw/standard scores, percentiles and norms used.
- State validity explicitly: PVT/SVT instruments, cut‑offs and interpretations when administered.
- Describe testing conditions: fatigue, effort, breaks, accommodations, distractions.
- Link to functioning: where you state it, connect profiles to ADLs/IADLs/school/work/safety.
For conversational input:
- Summarise each domain while fresh: brief domain recaps improve accuracy.
- Invite collateral input aloud: for the ‘Information Sources’ section.
- Dictate recommendations explicitly: do not rely on inference.
Frequently Asked Questions
A holistic assessment capturing symptom burden, goals-of-care discussions, psychosocial and spiritual needs, and a coordinated care plan. Aligned with South Africa’s National Policy Framework and Strategy on Palliative Care (2017–2022).
What Information it Includes:
- Reason for visit (who requested and why)
- Symptoms with severity scores
- Psychological, spiritual and social context
- Goals of care and preferences
- Pharmacologic/non‑pharmacologic plan and coordination
How to improve
- Quantify symptoms: use 0–10 scores where possible (pain, dyspnoea, etc.).
- State performance status: ECOG/Karnofsky if you mention it.
- Name responsible persons and timelines: for each coordination item.
For conversational input:
- Repeat goals aloud: verify preferred place of care, code status, and priorities.
Frequently Asked Questions
Short, problem‑focused update for ongoing palliative‑care patients—tracking symptom changes, psychosocial issues and plan adjustments. Consistent with South Africa’s National Policy Framework and Strategy on Palliative Care (2017–2022).
What Information it Includes:
- Updated symptom scores
- Psychosocial/spiritual updates (if any)
- Goals-of-care review
- Medication tweaks and other interventions
- Next review plan
How to improve
- Compare to last visit: “pain 7 → 4” guides titration and trajectory.
- Record breakthrough use: name drug, dose and frequency if discussed.
For conversational input:
- Confirm side‑effects and benefit: brief check‑ins improve dosing accuracy.
Frequently Asked Questions
A plain‑language leaflet that explains the diagnosis, key findings, treatment plan and self‑care instructions directly to the patient.
What Information it Includes:
- About the condition (simple explanation)
- What was found and why it matters
- Treatment plan (medicines and non‑drug items)
- Everyday self‑care advice
- Red‑flag symptoms and follow‑up
How to improve
- Avoid jargon: define unavoidable terms in brackets.
- Tell the patient what to do: be action‑oriented and specific on dosing and self‑care.
- Include red‑flags you said: so the safety‑net is clear.
For conversational input:
- Check understanding aloud: patient questions highlight what to include.
Frequently Asked Questions
Outlines baseline function, therapy goals, interventions delivered and progression criteria—ideal for PT, OT or rehab settings.
What Information it Includes:
- Functional baseline and assistive devices
- Short‑ and long‑term functional goals
- Interventions delivered
- Progression criteria and home exercise plan
- Follow‑up and outcome measures
How to improve
- Make goals measurable: e.g., “walk 20 m with quad cane”.
- Speak dosage: reps, sets, hold time and frequency for exercises.
- State precautions: weight‑bearing limits, ROM restrictions if relevant.
For conversational input:
- Verbalise demonstrations: briefly describe the exercise while teaching it.
Frequently Asked Questions
Pre‑anaesthetic evaluation covering indication, risk stratification, airway, planned procedure and pre‑op orders. Aligned with the South African Society of Anaesthesiologists (SASA) Practice Guidelines (2022) for peri‑anaesthesia care.
What Information it Includes:
- Surgical indication and urgency
- Risk stratification (ASA, comorbidities, anticoagulation)
- Frailty/functional capacity and airway risks
- Anaesthetic evaluation and fasting/NPO status
- Investigations and planned procedure details
- Medication management and pre‑op orders
How to improve
- Quote airway metrics: Mallampati, mouth opening, thyromental distance.
- Name anticoagulants: and clearly state stop/continue plan if discussed.
- Add peri‑op instructions: VTE prophylaxis, antibiotics, NPO orders if you state them.
For conversational input:
- Confirm consent aloud: for anaesthesia and blood products when applicable.
Frequently Asked Questions
A comprehensive admission note for psychiatric inpatients. Captures legal status, presenting concerns, psychiatric and substance histories, MSE, risk, initial investigations and the management plan. Aligned with HPCSA record‑keeping standards and local psychiatric guidance (e.g., SASOP treatment/good practice resources).
What Information it Includes:
- Admission context, pathway and Mental Health Care Act legal status
- Presenting psychiatric concerns and precipitating events
- HPI; past psychiatric history; substance use history
- Medical/surgical history; current meds; allergies
- Psychosocial history; family psychiatric history; developmental/educational history
- Collateral information (if provided)
- Review of systems; physical exam; MSE
- Capacity assessment (if documented)
- Risk assessment (self/others/vulnerability)
- Baseline investigations; provisional diagnoses/problem list
- Initial management plan; admission orders confirmed
How to improve
- State legal status and forms: voluntary/assisted/involuntary and paperwork when applicable.
- Differentiate observation vs report: MSE items should be what you observed or explicitly stated.
- Be exact on risk: ideation, intent, plan, means and protective factors—avoid vague phrasing.
- Name substances and timing: type, quantity, frequency and last use if discussed.
For conversational input:
- Use direct risk questions: ask and restate answers about suicidality, violence and access to means.
- Summarise the plan aloud: meds, observation level, referrals and follow‑up actions.
Frequently Asked Questions
A comprehensive psychology consultation note aligned with HPCSA rules and PsySSA practice resources. Documents presenting concerns, relevant background, MSE, assessments (if any), formulation, and plan—recording only what you explicitly state.
What Information it Includes:
- Presenting problem and impact
- History of presenting problem
- Personal/developmental background
- Psychiatric/medical history and medications
- Psychosocial factors and substance use
- Mental Status Examination
- Assessments (if used) with scores
- Formulation/impressions and plan
How to improve
- Capture the client’s voice sparingly: short quotes or close paraphrases for core concerns.
- Differentiate observation vs inference: MSE should reflect observed or explicitly stated features only.
- Name tests and scores precisely: if you used them; no estimation.
For conversational input:
- Ask for duration and impact: symptoms and everyday functioning.
- Close with a plan: state modalities, frequency, and follow‑up timing.
Frequently Asked Questions
A focused daily psychiatry progress note for inpatient or telehealth follow‑up. Tracks change since last contact across Subjective, Objective (including MSE), Risk, Interventions, Medications, Coordination and the Plan. Aligned with APA guidance on psychiatric evaluation structure and HPCSA record standards.
What Information it Includes:
- Subjective updates since last review
- Objective findings including MSE (if stated)
- Diagnostics/monitoring data reviewed
- Psychosocial and functional updates
- Risk assessment (self/others/safeguarding)
- Interventions and response
- Medication administration and changes
- Coordination and plan
How to improve
- Track change explicitly: say what is better, unchanged, or worse since the prior note.
- Detail MSE selectively: include only the domains described today.
- Be specific in risk: ideation, intent, plan, means and protective factors—avoid vague terms.
For conversational input:
- Signal sections aloud: “Subjective… Objective… MSE… Risk… Plan…”.
- Number the plan: create clear action lists (meds, monitoring, safety, follow‑up).
Frequently Asked Questions
A structured suicide/self‑harm risk assessment aligned with HPCSA mental‑health record standards and NICE guidance on self‑harm assessment and management. Documents ideation, intent, plan, access to means, risk/protective factors, formulation and safety planning—recording only what you state.
What Information it Includes:
- Reason for assessment and context
- MSE observations (if stated)
- Ideation, plan, intent, access to means
- Risk and protective factors
- Psychosocial context and substance use
- Collateral information (if any)
- Clinical formulation and stated risk level
- Management and safety plan; crisis resources
How to improve
- Anchor to specifics: frequency, intensity, triggers and timing.
- Differentiate desire vs intent: and feasibility of any plan.
- Clarify access to means: availability and storage details if discussed.
For conversational input:
- Use direct language: ask about thoughts, plans, intent, past behaviour and means.
- Read back the safety plan: confirm understanding of steps and crisis lines.
Frequently Asked Questions
Structured imaging report covering study details, technique, findings, impression and recommendations—applicable to XR, CT, MRI, ultrasound and more. Aligned with the ACR Practice Parameter for Communication of Diagnostic Imaging Findings.
What Information it Includes:
- Study details and clinical indication
- Technique and contrast (if applicable)
- Systematic findings with measurements
- Impression (diagnosis or differentials)
- Recommendations or follow‑up imaging
How to improve
- State modality/body part first: then indication.
- Provide measurements and descriptors: size, attenuation/signal, enhancement, distribution.
- Mention comparison studies explicitly: with dates and key differences.
For conversational input:
- Use standard lexicons when relevant: BI‑RADS, PI‑RADS, LI‑RADS with categories.
Frequently Asked Questions
A formal letter to another provider summarising the patient’s condition and the precise reason for referral.
What Information it Includes:
- Concise reason for referral
- Relevant background and current presentation
- Exam/investigations already performed
- Specific question and urgency for the referral
How to improve
- State the question clearly: e.g., “Opinion on suitability for TAVI”.
- Include essentials only: keep the letter tight and focused on the ask.
For conversational input:
- Tell the patient you’re referring them: this cue helps frame the letter properly.
Frequently Asked Questions
A structured surgical consultation note capturing referral reason, focused history, condition‑specific risks, examination, investigations and a clear management plan. Optimised for breast and thyroid conditions, but suitable for general‑surgery presentations. Aligned with HPCSA clinical documentation standards and American College of Surgeons perioperative consultation guidelines.
What Information it Includes:
- Consultation metadata and demographics (if stated)
- Presenting complaint and chronology
- Condition‑specific risks (breast/thyroid or other)
- Past medical/surgical history; meds; allergies
- Family history of malignancy (if stated)
- Lifestyle/psychosocial context impacting risk
- Detailed examination findings (incl. breast/neck if applicable)
- Investigations (pathology, imaging, labs)
- MDT discussion (if any) and prognostic features
- Assessment and management plan with follow‑up
How to improve
- State laterality and precise location: clock‑face, quadrant or distance from nipple for breast.
- Give investigation dates: mammogram/US/MRI/FNA histology dates anchor the narrative.
- Speak receptor status verbatim: ER/PR/HER2/Ki‑67 when available.
For conversational input:
- Narrate key exam findings: size, consistency, mobility, skin/nipple changes, nodes.
- Read relevant labs aloud: e.g., “TSH 2.1 mIU/L on 2024‑03‑01”.
- State next steps during the consult: imaging, referrals and timing.
Frequently Asked Questions
Operative note detailing background, technique, intra‑operative events and post‑op considerations—for theatre records or publications. Aligned with the Royal College of Surgeons’ Good Surgical Practice standards for operative documentation and communication.
What Information it Includes:
- Background and objectives
- Pre‑operative considerations
- Surgical technique (sequential steps)
- Immediate outcome and complications
- Post‑operative plan and prospects
- Additional information (consent, trials, counts) if stated
How to improve
- Describe key steps plainly: approach, key landmarks, haemostasis and fixation.
- State EBL and fluids: provide exact numbers if discussed.
- Dictate implant details: name, size, serial/lot where relevant.
For conversational input:
- Verbalise intra‑op events in real time: e.g., “Small serosal tear repaired”.
Frequently Asked Questions
A structured biopsychosocial assessment aligned with SACSSP professional conduct/ethics requirements and recognised social work case‑management standards. Documents development history, family context, education/employment, legal issues, social/spiritual factors, substance use, prior treatment, MSE‑style observations, evaluation and planning—only as explicitly stated.
What Information it Includes:
- General info and reason for referral
- Development history (birth/early milestones)
- Family history and trauma exposure
- Education, employment and financial history
- Legal history (arrests and current matters)
- Social and spiritual history (living situation, supports)
- Lifetime substance use patterns
- Treatment history
- Medical screening and medications
- Mental Status Exam (observations, mood, cognition, risk)
- Evaluation and planning
How to improve
- Anchor timelines: ages, durations and key dates improve coherence.
- Distinguish quotes vs summaries: use brief quotes only for pivotal statements.
- Name agencies and roles: schools, employers, courts, social services if relevant and stated.
- Only include what’s voiced: sensitive items appear only if you state them.
For conversational input:
- Check consent for collateral: state who provided information and consent status.
- Recap domain by domain: summarise childhood, family, school/work and legal before moving on.
Frequently Asked Questions
A collaborative care‑planning document for clients with co‑occurring mental health and substance use disorders. It captures clear goals, triggers, coping strategies, supports, treatment preferences, relapse‑prevention steps, and strengths, concluding with a signed acknowledgement. Aligned with SAMHSA guidelines (2018) and the South African National Mental Health Policy Framework and Strategic Plan (2023–2030).
What Information it Includes:
- Patient information if provided
- Diagnoses (psychiatric/medical and substance use) and current medications
- Short‑term (≤3 months) and long‑term (6–12 months) recovery goals
- Triggers and early warning signs
- Coping strategies (established and to develop)
- Support system: contacts and defined roles
- Treatment preferences and medication/modality concerns
- Wellness practices and planned self‑care
- Relapse‑prevention actions and team support
- Personal strengths and external resources (e.g., AA/NA) as stated
- Signature and acknowledgement text
How to improve
- Dictate headings aloud: say “Short-term goals…” or “Support contacts…” before listing items so content lands in the correct section.
- Quote detail in full sentences: include who, what, frequency and timeframe to avoid fragmented bullet points.
- Speak numbers and timeframes clearly: specify “three sessions per week for 12 weeks” rather than “a few sessions”.
- Bundle paired data together: state each support person immediately with their role to prevent mismatched entries.
- Flag omissions explicitly: if no data exist for a section, say “No warning signs discussed” so you can confirm intentional gaps.
For conversational input:
- Recap each goal after agreement: restating it verbatim improves transcription fidelity.
- Spell uncommon programme names: community resources and acronyms stay accurate when spelled once.
- Pause between sections: brief pauses reduce the risk of triggers, coping strategies and supports blending together.
Frequently Asked Questions
A client‑centred development plan used in clinical social work and case management. It documents strengths and needs, a goal‑and‑action list with responsible persons, an evaluation/summary, and formal agreement with signatures. Aligned with the SACSSP Code of Ethics (2019) and NASW Standards for Social Work Case Management (2013).
What Information it Includes:
- Patient information if provided
- Strengths and weaknesses (as stated)
- List of set Goals and Action Plans
- Evaluation / Summary of progress (if provided)
- Agreement statement and signature lines
How to improve
- Introduce each goal with the date: saying “Goal set on 12 August 2025…” ensures the list captures both timeline points.
- Group goal elements together: state goal, objectives, responsible persons and outcomes consecutively before moving to the next goal.
- Use consistent phrasing for actions: begin steps with verbs (“Attend…”, “Submit…”) to keep objectives clear.
- Clarify outcome status: specify “completed”, “in progress”, or “pending review on [date]” so the system records the state accurately.
- Mention review checkpoints: saying “review in four weeks” ensures follow-up cadence is captured.
For conversational input:
- Spell names and titles: practitioners, agencies and programmes are transcribed correctly when spelled once.
- Confirm each action step aloud: brief read-backs reduce missed responsibilities.
- Pause between goals: a short pause signals the model to start a new numbered entry.
Frequently Asked Questions
A structured discharge planning document for dual‑diagnosis programmes. It summarises the admission reason, diagnoses, interventions delivered, progress and insight, strengths and risks, and the post‑discharge plan (follow‑ups, aftercare, supports, medication compliance, lifestyle recommendations), with a closing acknowledgement and signatures. Aligned with the South African National Mental Health Policy Framework (2023–2030) and SACSSP Scope of Practice Guidelines (2021).
What Information it Includes:
- Facility/programme details
- Case information: identifiers, admission/discharge dates, team members
- Presenting problem / reason for admission
- Diagnoses: primary psychiatric and secondary/substance use
- List of interventions with Intervention Type, Frequency/Sessions, Focus Areas
- Patient progress and insight
- Identified strengths and risks/concerns
- Post‑discharge plan
- Patient acknowledgement and signature lines for patient and social worker
How to improve
- State programme details first: begin with facility and programme text before moving to case specifics to lock in the header content.
- Narrate interventions sequentially: give intervention type, number of sessions and focus in a single sentence for each item.
- Quote follow-up logistics: include dates, locations, contact numbers and booking status to enrich the appointments list.
- Label risk statements: start with phrases like “Risk:” or “Concern:” so they render clean bullet points.
- Read signature lines verbatim: stating the acknowledgement text ensures the required wording appears exactly.
For conversational input:
- Verify names and numbers aloud: spell surnames and read contact digits in pairs to prevent transcription errors.
- Segment post-discharge subsections: say “Follow-up appointments…”, “Medication compliance…”, “Aftercare…” to keep lists distinct.
- Confirm pending items: note “pending confirmation” or “to be arranged” so the document reflects outstanding tasks.
Frequently Asked Questions
A counselling session note tailored to telehealth. Captures platform, consent, privacy, session content, MSE (if observed), risks, interventions and plan. ‘Session Information’ fields may be marked ‘N/A’ when not discussed. Aligned with HPCSA Telehealth guidance, APA telepsychology guidance (updated), and ATA telemental health practice guidance.
What Information it Includes:
- Platform/modality, locations, consent/privacy
- Presenting concerns and session goals
- Relevant background
- MSE and functioning (if observed)
- Risk and safeguarding (if discussed)
- Interventions, engagement and response
- Telehealth considerations and limitations
- Coordination, assessment and plan
How to improve
- State telehealth essentials up front: platform, location, consent, privacy and emergency plan.
- Note limitations/adaptations: bandwidth issues or accommodations if relevant.
- Name techniques and tasks: so they appear clearly in the plan.
For conversational input:
- Open with context: “We are on [platform] by [video/phone]; where are you located?”
- Confirm consent and contacts: document these aloud if applicable.
- Summarise goals at the end: and restate homework or next steps.
Frequently Asked Questions
Captures details unique to remote encounters—platform, consent, locations, remote exam limitations—in addition to standard HPI, assessment and plan. Aligned with HPCSA Telehealth guidance and American Telemedicine Association recommendations.
What Information it Includes:
- Platform, consent and location details
- Presenting concerns and HPI
- Remote examination and limitations
- Investigations reviewed
- Assessment, plan and safety‑net
- Technical issues (if any)
How to improve
- State both locations: provider and patient (if discussed) for regulatory clarity.
- Note limitations: what could and could not be assessed remotely.
- Include home/device vitals: quote exact values and units when provided.
For conversational input:
- Ask the patient to read measurements aloud: then restate them clearly.
