Clinicians

Writing the note

Templates, dot-codes and SmartPhrases — and letting the AI draft the whole thing from the visit, then editing it.

8 min · Clinicians · lesson v1

The note is yours. The software will help you write it, from a scaffold, a template, or the visit itself — but it never puts words in your mouth unasked.

The scaffold

  1. The Note tab opens on the empty structure: Chief Complaint, History of Present Illness, Review of Systems, Physical Exam, Assessment, Plan.

    The banner above says what the tab is for: Your note — unsigned, and nothing writes into it on its own. Type here, or load a template with its dot-code (e.g. .followupnote). At sign-off you can have the AI write the whole note from the visit.

    ✎ Edit note switches to typing; ✓ Done goes back to the preview.

    Screenshot pending capture

The status flag next to the heading is one of three things, and it is worth knowing which you are looking at:

  • Not written yet — untouched
  • Edited — you typed in it
  • AI draft — edited by you — it started as an AI draft and you changed it

↺ Clear note empties it back to the scaffold, with the message Cleared — the note is back to the empty section scaffold.

Templates, dot-codes and SmartPhrases

Your practice's templates load two ways: pick one from Insert template…, or type its dot-code — .followupnote and the like — directly in the note.

If you already have text, you are asked rather than overwritten: Replace your note with the [title] template? Your current text will be kept below it if you choose Insert.Replace, Insert below, Cancel.

SmartPhrases expand as you type them, then a space. You will see a confirmation like 3 SmartPhrases expanded.

Sometimes you'll get a suggestion: ✨ AI suggests the [title] .followupnote template for this visit. with Apply. It is a suggestion about formatting, not content.

Letting the AI write it

  1. At sign-off, the note editor grows a second row: Write in template: with a picker (Standard SOAP (no template) by default) and the button ✦ Write note with AI.

    Its hint is precise about what it reads: Reads everything said this visit plus the orders you confirmed, the differential, and the codes awaiting attestation — then writes it as a note, not a transcript. A draft: read it, edit anything, and you sign it.

    While it works the button reads Writing the note…; afterwards it becomes ✦ Rewrite with AI.

    Screenshot pending capture

When it succeeds you get Draft written by [model] — unsigned. Review and edit before signing.

Three honest failure messages worth recognising:

  • Nothing was captured for this visit, so there is no conversation to write from — type the note yourself. — the transcript is empty and the button is disabled
  • No AI key is configured for this office, so only the template skeleton was inserted — write the note yourself.
  • Could not write the note (…). Nothing was changed — try again, or write it yourself.

When not to use it

The AI writes from the conversation. If the consultation happened largely in silence — a procedure, an examination with little talk, a visit where the microphone failed — there is little for it to work from, and a note written from thin material is worse than one you typed in four sentences.

It is also the wrong tool when the important part of the visit is something you decided afterwards, on reflection. Say that in your own words.

What usually goes wrong

Signing an AI draft you skim-read. It is a draft written from a transcript that flags its own uncertainty. You are signing it.

Expecting a transcript. It writes a note. If you want to see what was said, open ⧉ Transcript.

Losing a note to a template. Read the replace prompt — Insert below keeps what you wrote.

Writing the note before the exam ends. The AI draft reads the whole visit; drafting early means it reads half of one.

Check yourself

No score, no account — just make sure you can answer these before you move on.

  1. Does anything write into your note automatically during the visit?

    Show the answer

    No. The note tab says so — Your note — unsigned, and nothing writes into it on its own. The AI drafts a note only when you press ✦ Write note with AI at sign-off, and what it produces is a draft you edit and sign.

  2. What exactly does ✦ Write note with AI read?

    Show the answer

    Its own hint answers this — Reads everything said this visit plus the orders you confirmed, the differential, and the codes awaiting attestation — then writes it as a note, not a transcript. If the transcript is empty the button is disabled, because there is nothing to write from.

  3. The note header says AI draft — edited by you. What does that tell a reader?

    Show the answer

    That the note began as an AI draft and you changed it. The three states are Not written yet, Edited (you typed it), and AI draft — edited by you. It is an honest provenance marker, not a demerit.