Verbalization
Good note quality starts with good audio quality. Be sure to place your device centrally between you and your patient and verbalize key findings. Verbalization can be done naturally during your conversation, or you can make additional recordings if you’d like to add any details after the patient visit.
Be aware of cross-talk (when multiple people speak at the same time) and extraneous noise sources (doors closing, papers rustling, etc.). If you feel like the recording may have been interrupted, it can be helpful to reiterate key information. Additionally, DeepScribe's models are currently only trained on English. If other languages are spoken, ensure that key information is reiterated in English either via translator or in a follow up recording.
Prompting
Prompting is a great way to ensure what you discuss in your encounter is documented correctly in your note. For certain note sections, we suggest different verbal prompts.
Reason for Visit/Chief Complaint
Example:
“Hello Mr. Smith, I see you’re here today for abdominal pain, is that correct?”
Physical Exam
The default physical exam for DeepScribe will bring in any abnormals mentioned during the recording. Let the system know you’re moving on to the exam by stating the body system and the word “Exam” before any abnormal findings and include details like laterality.
Example:
“Let’s move on to your exam... Your heart sounds good, but when I listened to your lungs your breath sounds were diminished throughout.”
Outcome: Respiratory: Diminished throughout.
Plan
Use the word “Plan” when finalizing your treatment plan.
Example:
“The plan moving forward is to continue with your current diet and follow up in 3 months”
Outcome: Continue with current diet. Follow up in 3 months.
Clarify Missing Context
Examples:
Patient states: “That medication you gave me last time worked well!”
Clinician clarifies: “I’m glad the Zoloft is helping you.”
Patient states: “My knee pain started on Thursday.”
Clinician clarifies: “So you’ve been experiencing this for about 4 days?”
Patient states: “My hip is falling out of its socket!”
Clinician clarifies: “I know it likely feels like that, but I don’t see any signs of dislocation.”
Patient states: “It hurts when I do this.”
Clinician clarifies: “So your left shoulder is hurting when lifting your arm.”
Dictation
DeepScribe’s dictation feature is designed to give you increased flexibility in how, when, and where you document. This feature has 3 primary functions.
Allows you to add dictation to your note to complement what the AI produced
Create “hybrid” notes by combining the befits of dictation and DeepScribe’s AI notes
Dictate notes in their entirety
DeepScribe’s dictation feature leverages Smart Refinement, a subsystem of our AI that allows clinicians to quickly dictate information into the note without having to speak verbatim. Smart Refinement automatically deciphers your dictations, combs them for grammar, spelling, and punctuation errors, and formats them into cohesive sentences.
To read more about how DeepScribe’s dictation feature works and how to use it, check out this how-to article.