Document Information
Detailed descriptions, sample reports and tips on generating excellent reports.
A comprehensive report capturing patient details such as chief complaint, medical history, examination findings, diagnostics, and treatment plans. Ideal for general consultations, follow-ups, and documenting patient encounters.
What Information it Includes:
- Chief complaint and history of present illness (HPI)
- Relevant past medical history (PMH) and diagnosed conditions
- Medications, allergies, family and social history
- Physical exam details, test results, and treatment plans
How to improve
- Be Specific: Clearly state the patient's chief complaint (e.g., 'Patient presents with a 3-day history of severe abdominal pain').
- Detail Medical History: List relevant medical history and chronic conditions (e.g., 'PMH: Hypertension, Type 2 Diabetes').
- Medication Clarity: Provide specific medication names, dosages, and frequencies (e.g., 'Medications: Lisinopril 10mg daily, Metformin 500mg BID').
- Exam and Plan: Summarize exam findings and recommended next steps (e.g., 'Physical Exam: Abdomen tender to palpation in the RLQ. Plan: Order CT scan of the abdomen and pelvis').
- Use Medical Terminology: Ensure accuracy by using correct medical terms.
For conversational input:
- Clarify Patient Statements: If the patient's description is vague, ask clarifying questions (e.g., 'Can you describe the pain more specifically?').
- Summarize Key Points Aloud: Periodically summarize key information (e.g., 'So, to recap, you've had this pain for three days, and it's worse after eating?'). This reinforces the information for the report and the patient.
- Explicitly State Findings: After an examination, state your findings aloud (e.g., 'On examination, I noted tenderness in the lower right quadrant').
- Clearly Outline the Plan: Verbally lay out the plan for the patient (e.g., 'We'll order a CT scan, and I'd like you to follow up in a week').
Frequently Asked Questions
No, only positive and relevant negative findings mentioned in the audio is noted. For instance, if there's no information on family history, the section will be omitted.
Yes, mention them in the audio (e.g., 'Lab results: WBC 15,000, Hemoglobin 12.0'). They will appear under 'Diagnostic Tests'.
Be specific, state 'No known allergies for antibiotics' or 'Patient denies any allergies' explicitly.
Yes, even a short note like 'Family History: Mother with history of breast cancer' will be included.
Dictating allows for more structure, but recorded conversation captures what was mentioned in the consultation. Each section of the report will automatically be populated with the relevant information.
A structured SOAP (Subjective, Objective, Assessment, Plan) medical note, ideal for organizing patient encounters and documenting clinical reasoning. Useful for progress notes, daily rounds, and outpatient visits.
What Information it Includes:
- Subjective: Patient's complaints, symptoms, and history
- Objective: Observable data, vital signs, test results
- Assessment: Clinical evaluation and diagnoses
- Plan: Treatment steps, orders, follow-ups
How to improve
- Separate Subjective and Objective: Clearly differentiate patient statements from objective measurements (e.g., 'Subjective: Patient reports headache. Objective: BP 140/90').
- Detail Physical Exam: Include specific physical exam findings (e.g., 'Objective: Lungs clear to auscultation, abdomen soft and non-tender').
- Comprehensive Assessment: Summarize the final assessment with diagnoses or working hypotheses (e.g., 'Assessment: Possible migraine vs. tension headache').
- Actionable Plan: Outline the plan with clear prescriptions, lifestyle changes, and follow-up instructions (e.g., 'Plan: Prescribe Ibuprofen 600mg PRN, follow up in 1 week').
- Quantify whenever possible: 'Objective: edema 2+ pitting' is better than just 'edema'.
For conversational input:
- Directly Address SOAP Sections: As you gather information, mentally categorize it into SOAP sections. You can even say aloud, 'So, subjectively, you're describing...'.
- Confirm Objective Data: When taking vitals or observing findings, state them clearly (e.g., 'Your blood pressure is 140/90, which is elevated').
- Verbalize Your Assessment: Articulate your thought process (e.g., 'Based on these findings, my assessment is that this could be...').
- State the Plan Clearly: Ensure the patient understands the plan (e.g., 'For the plan, we'll start with this medication and schedule a follow-up').
Frequently Asked Questions
List each issue under Subjective and Objective, then consolidate them in the Assessment (e.g., 'Assessment: Multiple complaints, likely related to anxiety').
Yes, mention them with specific values (e.g., 'Objective: Chest X-ray shows no infiltrates').
Document your differential diagnoses or working hypotheses (e.g., 'Assessment: Differential includes pneumonia, bronchitis').
While adaptable, a dedicated 'Surgery Report' might be more suitable for detailed surgical documentation.
A formal letter to another healthcare provider, summarizing the patient's condition and the reason for referral. Essential for coordinating patient care and ensuring continuity of treatment.
What Information it Includes:
- Patient's background and relevant medical history
- Current presentation, symptoms, and diagnostic findings
- Specific reason for referral and requested services
How to improve
- Clarity of Purpose: Clearly state the reason for referral and the specific expertise needed (e.g., 'Referral to cardiology for evaluation of persistent chest pain').
- Comprehensive Summary: Provide a concise but thorough clinical summary (e.g., 'Patient with a history of hypertension and hyperlipidemia presents with...').
- Specific Requests: Outline any specific tests, procedures, or consultations needed (e.g., 'Request for cardiac stress test and echocardiogram').
- Contact Details: Ensure your contact information is included for easy communication and feedback.
For conversational input:
- State Referral Intent Clearly: During the consultation, state your intention to refer the patient and the reason (e.g., 'Based on these findings, I'm going to refer you to a cardiologist').
- Summarize Relevant History Aloud: Briefly summarize the patient's relevant history and current presentation (e.g., 'This patient has a history of... and is now presenting with...').
- Explicitly Mention Requested Services: Clearly state what you're requesting from the specialist (e.g., 'I'm requesting an evaluation for... and a possible...').
- Confirm Key Details with Patient: Ensure the patient understands the referral and the reasons behind it.
Frequently Asked Questions
Yes, clearly articulate each reason in the transcript.
Yes, relevant results support the referral and provide context.
Use 'Dear Colleague' or 'To the [Specialty] Department' if you don't have a specific name.
The letter should include a heading (e.g., 'RE: Patient Referral'), an introduction, relevant history, the referral request, and a closing.
This depends on your system. If possible, mention the attached results in the letter. If not, make sure they are included in the patient's record and accessible to the specialist.
A comprehensive psychological consultation report, capturing presenting problem, history, psychosocial factors, mental status examination, clinical impressions, and recommendations. Essential for documenting psychological evaluations and treatment planning.
What Information it Includes:
- Presenting problem details: (patient's statements, concerns)
- History of the issue: personal/developmental background, psychosocial history
- Mental status examination: (appearance, speech, mood, thought process, etc.)
- Clinical impressions: including potential diagnoses or hypotheses
- Recommendations: or proposed therapy plans
How to improve
- Direct Client Statements: Provide direct quotes or paraphrased statements from the client regarding their main issues or complaints (e.g., 'Client reports, "I've been feeling overwhelmed and anxious for weeks."').
- Detailed History: Mention relevant developmental, social, or familial details (e.g., 'Client reports a history of childhood trauma and social isolation').
- Specific Mental Status Observations: Include specific observations from the mental status exam (e.g., 'Client's mood was anxious, affect restricted, thought process linear but preoccupied with worries').
- Clear Recommendations: Clearly state recommended treatments or follow-ups (e.g., 'Recommend weekly individual therapy sessions focusing on cognitive behavioral techniques').
For conversational input:
- Capture Key Phrases: When the client describes their symptoms, try to capture key phrases they use, as these are valuable for the report.
- Note Non-Verbal Cues: Pay attention to and verbally note non-verbal cues (e.g., 'Client appeared restless and fidgety throughout the session').
- Explicitly State Mental Status Observations: As you conduct the mental status exam, articulate your observations (e.g., 'Client's speech is rapid, and their affect appears labile').
- Summarize Impressions Aloud: Summarize your clinical impressions for the client (e.g., 'Based on our discussion, it seems you're experiencing symptoms consistent with anxiety and possible depression').
- Collaboratively Develop Recommendations: Involve the client in the development of recommendations (e.g., 'We recommend weekly therapy sessions. Does that sound manageable for you?').
Frequently Asked Questions
Only explicitly mention it if the client directly discusses it. Do not speculate or make assumptions.
Yes, if you mention those results in the audio (e.g., 'Beck Anxiety Inventory score was 25, indicating moderate anxiety').
The system will return only what you disclosed in the transcript. Focus on what is relevant and known.
Anonymize or omit sensitive identifiers. Focus on clinical details and avoid unnecessary personal information.
Note the differing accounts. For example 'Clients reports X, family reports Y'. Do not make assumptions on which is correct unless you have other supporting data.
