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Starting and Conducting Visits with Custom Notes

This guide explains how to use the custom notes system to record patient visits (with proper consent) or as a free-form dictation tool for generating documentation.

Overview​

The AIRAdoc documentation system can be used in two general ways:

  1. Recording the Patient Encounter: Document patient encounters (with patient consent) to generate structured notes.
  2. Free-Form Dictation: Generate notes from recordings for any documentation needs

Both modes use AI-powered transcription and template-based note generation to streamline your documentation workflow.

Before Starting a Visit​

For Patient Visits​

  • Obtain Consent: Ensure you have proper patient consent for audio recording
  • Template Selection: Choose an appropriate custom note template for the visit type. Don't worry, you can change templates later if you decide a different template is better for the visit

Starting a New Visit​

Step 1: Access the Visit Interface​

  1. Navigate to the main Scribe page by clicking on the Scribe button from the main side panel
  2. Click on "New Visit" button at the top of the Documents list

Step 2: Patient Information​

Enter patient name or identifier

Step 3: Category​

  • Notes: Customizable note templates using pre-built element blocks
  • Procedures: Customized templates for procedures
  • Reports: Customized templates for reports, such as radiology or other findings
  • Letters: Customized templates for letters to patients, colleagues or other depending on your needs

Step 4: Select Template​

  • Browse Available Templates: View your templates. If you cannot find what you are looking for, you can always add a new template from the Templates page.

Step 5 Pronoun (optional)​

  • Select the appropriate pronoun for the patient, so that the AI will document correctly

Video Visit (for telemedicine)​

  • Check this box if you are recording a video visit. When the visit starts, you will see an additional dialogue that allows you to select a window where the application should grab the recording. Select the window where your video visit is taking place.

Conducting the Visit​

Recording Phase​

  1. Start Recording: Click the record button to begin audio capture. If your browser asks for permission to access the microphone, click "Always Allow."
  2. Conduct Your Visit: Speak naturally while following your usual workflow.
  3. Monitor Recording: Watch the audio level indicator to ensure clear capture.
  4. Pause if Needed: Use the pause button for breaks or interruptions. You can restart the visit at any time.
  5. Stop Recording: Click stop when the visit is complete.

Post-Visit Processing​

Processing​

  1. Transcription: The system automatically transcribes your audio recording when you hit "End Visit"
  2. Note Generation: A formatted note is created with all relevant details

Review and Editing​

  1. Initial Review: Review the generated note for accuracy
  2. Edit Content: To edit, either click the Edit Note button or click on the document
  3. Add Missing Information: Supplement with any details not captured in audio
  4. Finalize Note: Ensure all required elements are complete, the click "Save and Copy." Your note will be saved to the clipboard, ready for pasting into your EHR.

Advanced Editing Options (In Edit Mode)​

  • Transfer Content: You can create an entirely new note, using the information contained in the current note. This is particularly helpful for generating a summary letter to a colleague or a patient. Simply select the new note format you want to create, and the new note will be generated.
  • Change Template: In Edit Mode, the current template is listed in a dropdown. If you decide a different template is more appropriate, you can simply change the selected template and the note will be reprocessed.
  • Reprocess: Next to the Copy & Save button are three dots. Click on these to reveal the option to Reprocess the visit. Clicking here will cause the note to be processed again, using the same template.
  • Resume Visit: Also found in the menu next to the Copy & Save button is the option to Resume Visit. This allows the user to add additional information to the visit / note. This can be used to add further test results, additional treatments, etc. After clicking on Resume Visit, recording will start again and the additional information can be provided. End Visit will once again process the note with both the old and new data included.

Copy Options​

  • AIRAdoc allows you to choose exactly how you want documents to be copied, since different EHR systems will have different requirements.
  • On the Copy Button (shown when the note is not in edit mode) click on the arrow at the right of the button
  • Plain: Copied text will be in simple style, no formatting
  • HTML: Complex styling, ideal for copying into a word processor
  • Custom: Plain text with simple HTML, good for browser based EHR systems

Tips for Best Quality​

  • Ensure You Are Using a Quality Microphone: Some computers require an external USB microphone
  • Speak Clearly: Enunciate words and use consistent terminology
  • Include Key Information: Cover all relevant clinical details. It is often helpful to clearly state the names of diagnoses, drugs and their doses during the visit, if appropriate. Patients appreciate this as well!
  • Add Short Dictation After the Visit: It often helps the quality of the final note to simply restate the diagnosis and treatment after the patient has left the room. You might also add in test results after the visit if relevant.
  • Natural Flow: Don't worry about perfect grammar - speak naturally