5 items found for ""
- DeepCura’s Revolutionary AI Clinical Containers: Transforming Patient Care Through Automated Reports
In today's fast-paced healthcare environment, clinicians need reliable, intelligent support to diagnose and treat their patients effectively. Introducing DeepCura's groundbreaking innovation—AI Clinical Containers. Not only can users download automated patient reports in PDF, but these reports can also be paired with top-notch research studies to generate clinical plans that are truly state-of-the-art. Unveiling Automated Patient Reports in PDF DeepCura provides an unparalleled feature that allows users to download automated patient reports, ranging from simple patient instructions to comprehensive History & Physical (H&P) notes. But why stop there? Pairing with Elite Scientific Resources To ensure that your clinical plans are backed by the most reliable data, DeepCura allows for an integration like never before. You can pair your automated patient report PDF with research studies from reputable scientific sources such as UpToDate or DynaMed. This creates a unique blend of personalized patient information and trusted scientific research. AI-Enhanced Clinical Plans: The Future is Here Once you’ve paired your patient report with a research study, DeepCura’s AI takes over. Unlike conventional AI models or chat-based solutions like Chat GPT, DeepCura's technology is engineered to generate clinical plans of unprecedented accuracy and relevance. When high-quality research reports serve as the context, the AI can produce clinical outputs that clinicians have never seen before. Introducing AI Clinical Containers: The Docker for AI-Assisted Diagnosis Inspired by the engineering concept behind Docker containers, DeepCura has pioneered the concept of AI Clinical Containers. In essence, we aim to be the Docker for AI-assisted diagnosis, packaging complex algorithms and high-quality data into a unified, user-friendly system. This innovative approach allows healthcare professionals to: Save Time: Automated reports speed up the data collection and diagnosis process. Improve Accuracy: Pairing with reputable research ensures that clinical plans are grounded in the latest scientific findings. Optimize Patient Care: Leveraging state-of-the-art AI algorithms for customized, real-time clinical decisions. Final Thoughts DeepCura is not merely an extension of existing AI models or chat-based solutions. It’s a transformative technology that promises to revolutionize the healthcare industry, starting from the fundamental level of patient reports and expanding to the complexities of state-of-the-art clinical plans. With DeepCura's AI Clinical Containers, clinicians are better equipped than ever to provide high-quality, personalized healthcare. Start integrating DeepCura into your clinical practice today and be a part of the future of intelligent healthcare.
- How to Mimic your Writing Style using DeepCura AI
In this article, we'll show doctors how to harness the power of our AI clinical workspace to enhance their automated clinical documentation. Though the training video provided focuses on Family Medicine, the underlying principles are the same to any medical specialty. Furthermore, we've provided AI note templates segmented by medical specialty below. Consider these templates as foundational resources or sources of inspiration, and feel free to adapt them to your requirements. How to Mimic your Writing Style using DeepCura AI: Step-by-step Guide: 1. Please watch the training video above to have an exact idea of how you can fine tune your clinical documentation. 2. Further Uses: Don't limit yourself to just H&P notes! DeepCura AI's capability extends to producing referral letters, medical reports, and more. All it requires is the appropriate data input, and within 60 seconds, your document will be ready. Here are some of the top Prompts that have been created from our users in different medical specialties: ------------------------------------------------------------------------------------------------------------------------- Internal medicine Prompt Generate a medical note using the following template. CHIEF COMPLAINT: HISTORY OF PRESENT ILLNESS: CURRENT MEDICATIONS: PAST MEDICAL HISTORY: HOSPITALIZATIONS: ALLERGIES: SOCIAL HISTORY: Smoking Status: ___________ Alcohol use: ___________ Caffeine use: ___________ Marital status: ___________ Racial background: ___________ Native language: ___________ Exercise habits: ___________ FAMILY HISTORY: Father: _______________ Mother: _______________ PREVENTIVE CARE: Hemoglobin A1c: ____________ Blood Glucose: ____________ Colonoscopy: ____________ COVID Vaccine: ____________ Last Complete Physical: ____________ Lipid Panel: ____________ PSA: ____________ REVIEW OF SYSTEMS: PHQ-2: ____________ VITAL SIGNS: Weight: _________; Height: _________; BMI: _________ Temperature: _________; Respiration Rate: _________; Pulse Rate: _________; Blood Pressure: _________ Pulse Oximetry: _________ PHYSICAL EXAMINATION: General: ____________ Lungs: ____________ Heart: ____________ Musculoskeletal: ____________ Diagnostic test results: DIAGNOSIS: PLAN: Utilize this transcript to extract the information. ------------------------------------------------------------------------------------------------------------------------- Family Medicine Prompt Generate a patient history and physical examination note with a detailed history of present illness (HPI) section with the following parameters and edit my physical exam default template only if you find any abnormal findings, follow this exact structure and remember to fill in the square brackets. Also remember to never include the square brackets themselves, delete them after you’ve filled in the corresponding information: Date: [Insert here today’s date and time if mentioned] Advanced Directive: [if mentioned, include advanced healthcare directive. If not mentioned, just state “Does not apply”] Dermatology: [describe latest dermatology visit and any relevant treatments or diagnoses. If a biopsy was ever taken describe date of procedure, reason for biopsy and biopsy report findings if available. If no dermatology visit is mentioned, state “Not mentioned” and if a visit occurred but there were no abnormal findings and no treatments administered, state “...”] HISTORY OF PRESENT ILLNESS: use this header for this section. Create a summary paragraph of the development of the patient’s present illness using the mentioned information. Write it in a well-written paragraph format with the following information in chronological order(from the first sign and symptom to the present): FAMILY HISTORY: use this header for this section. Include any relevant family history only including mother, father, maternal and paternal grandparents, children, and siblings. Only include other family members in case of cancer history. SOCIAL HISTORY: use this header for this section. Remember to only edit the default answers if there are abnormal findings, otherwise, leave them as is. Remember to fill in the square brackets with the relevant information. Tobacco: [if patient is a smoker and if mentioned state number of cigarettes per day. Otherwise state “Does not smoke”] Alcohol: No alcohol excess. Drug use: No drug use. Stress reduction/hobby: [include any hobbies or stress reduction techniques if mentioned. Otherwise state “Not mentioned”] Supplements: [include any supplements. Otherwise state “None mentioned”] DIET: use this header for this section. If no information was given, state “Not mentioned” Breakfast:________ Lunch:________ Dinner:________ Snack:________ Elimination diet:________ Allergies: [if the patient states he or she has no allergies, write “No allergies”, if any allergies are mentioned, describe the allergen and the reaction that occurs if mentioned] Vaccines: if the following vaccines were administered, describe the number of doses and the date of the last dose. If the vaccine wasn’t administered state “Not administered” Tetanus:________ Pneumovax:_______ Prevnar:______ Flu vaccine:_______ Exercise: [if any form of exercise is mentioned describe frequency, type(s) of exercise, the duration of each exercise session and when the exercise regimen began. If the patient does not exercise mention that.] MEDICAL HISTORY: use this header for this section. Add any past medical history that is mentioned. Medications: [include any medications, including dosage and frequency. Otherwise, state “None mentioned”] SURGICAL HISTORY: use this header for this section. Add any surgical history, including date of surgery, if there were any complications, if a biopsy was performed and the results of the biopsy if applicable. REVIEW OF SYSTEMS: use this header for this section. VERY IMPORTANT NOTE: this section has default answers for normal findings. DO NOT change any of it unless you note an abnormal finding during the transcript. If you do note an abnormal finding, add it to the corresponding section. Constitutional: No fever/chills. No weight change. No appetite change. No sleep problems. No snoring. Eyes: No visual change. Ears, nose, throat, mouth: No headache, No runny nose. No hearing difficulty. Respiratory: No cough. No dyspnea. Cardiovascular: No chest pain. No palpitations. No faintness. No edema. Gastrointestinal: No abdominal pain. No heartburn. No nausea. No vomiting. No diarrhea. No constipation. No melena. BM daily. Genitourinary: No urinary frequency. No dysuria. No hematuria. Musculoskeletal: No back pain. No joint pains. No morning stiffness. Neurological: No localized weakness. No paresthesias. No tremor. No history of concussion/head injury. Integumentary: No rash. No lesions. Psychiatric: No emotional stress. No depression. No anxiety. Endocrine: No temperature intolerance. Hematologic/lymphatic: No easy bruising. Allergic/immunologic: No hay fever. No excess infections. No tick bites. Environmental: No chemical exposures. No mold exposure. PHYSICAL EXAMINATION: use this header for this section. VERY IMPORTANT NOTE: this section has default answers for normal findings. DO NOT change any of it unless you note an abnormal finding during the transcript. If you do note an abnormal finding, add it to the corresponding section. Appearance: Alert, cooperative, in no distress. Vital signs: Weight: [lbs] Height: [inches] BMI: [calculate the BMI based on the weight and height of the patient] Temperature: _________ Respiration Rate: _________ Pulse Rate: _________ Blood Pressure: _________ Pulse Oximetry: _________ Skin: Warm, dry; No cyanosis. No suspicious lesions. Eyes: No conjunctival pallor. Ear, nose, mouth, and throat: Mucous membranes moist. Nares clear. Pharynx clear. Teeth okay. Neck: Normal thyroid, No lymphadenopathy, No bruit, No JVD Chest/respiratory: No rales, No rhonchi, No wheezes; breath sounds equal bilaterally. Heart/cardiovascular: No irregularity; No murmur, No gallop. Abdomen/gastrointestinal: Soft; No tenderness; No HSM. Back: No deformity. Genitourinary: Deferred Extremities: No deformity. Neurological/psychiatric: Alert and oriented; No focal weakness. DTR's equal bilaterally. Normal gait. No tremor. Lymp: No enlarged neck, axillary, or groin lymph nodes. LABORATORY/IMAGING: use this header for this section. Add any relevant laboratory tests and/or imaging with results if possible. Remember to fill in the brackets with the relevant information. Colonoscopy: [describe latest colonoscopy if relevant. Include date of procedure, relevant findings, if a biopsy was performed, and if available, biopsy results.] Occult Blood: [mention any test results for occult blood if they’re mentioned. If not mentioned state “not mentioned”] PAP: [describe latest Pap test if relevant. Include date of procedure, and relevant findings. If the patient has never had a Pap test just write that.] Mammogram: [describe latest mammogram if relevant. Include date of procedure and relevant findings.] Breast USS: [describe latest breast ultrasound if relevant. Include date of procedure and relevant findings.] Densitometry: [describe latest densitometry if relevant. Include date of procedure and relevant findings. If mentioned, include T scores.] PSA: [if relevant describe prostate-specific antigen results] DRE: [if relevant, describe direct rectal exam findings. If the test was done but there were no abnormal findings state “No abnormalities found.”] IMPRESSION: use this header for this section. Add the diagnostic impression with the corresponding ICD-10 code. PLAN/FOLLOW-UP: Use this header for this section. If a thorough treatment plan is not given, suggest one based off the given patient encounter, or add to what has been given. Put this in list form with bullet points. ------------------------------------------------------------------------------------------------------------------------- Otolaryngology Prompt Generate a SOAP note with a detailed Subjective section with the following parameters and edit my physical exam default template only if you find any abnormal findings, please follow this exact structure: Patient Name: AID: DOB: PCP: Date of encounter: Subjective (Please make this more detailed and include past surgical history): Physical Exam (Replace these values only if you find abnormal finding from the transcript): - General: No acute distress. Voice is clear. Managing secretions. - Ears: Right EAC clear; tympanic membrane clear and intact; no middle ear effusion. Left EAC clear; tympanic membrane clear and intact; no middle ear effusion. - Nose: Septum midline. No turbinate hypertrophy. Normal appearing mucosa. - Oral Cavity/Oropharynx: No masses or lesions. Tonsils normal appearing. Oropharynx clear. - Neck: No cervical adenopathy. No thyroid masses palpable. - Face: Intact and symmetric facial movement. - Neuro: Cranial nerves grossly intact. - Abnormal endoscopic findings (list abormal findings from laryngoscopy or nasal endoscopy. Delete title and section if not mentioned): Nasal Endoscopy (Delete title and section if not mentioned. Replace these values only if you find abnormal finding from the transcript): - Indication: Anterior rhinoscopy insufficient for visualization of entire nasal cavity and nasopharynx. - Nasal cavity: Nasal mucosa healthy appearing. No turbinate hypertrophy. The middle meatus and sphenoethmoid recess were clear. - Nasopharynx: Normal appearing. Laryngoscopy (Delete title and section if not mentioned. Replace these values only if you find abnormal finding from the transcript): - Indication: Unable to visualize larynx with a mirror. - Nasal cavity and nasopharynx: Healthy mucosa. No pus or polyps. Nasopharynx clear. - Oropharynx: Tongue base normal appearing. - Supralottis: Epiglottis free of disease. Arytenoid cartilages with healthy mucosa. False vocal folds and the visible ventricle were normal appearing. - Glottis: The true vocal folds were normal in appearance and movement. - Hypopharynx: The pyriform sinuses were free of disease. The post-cricoid area was not-edematous. There were no pooling secretions. - Subglottis: The visible subglottis was patent. Audiogram (do not display this section or title if an audiogram is not mentioned): Assessment: Plan: (Leave 4 lines after the last Plan item) Extremely Important Note: make only the assessment and plan portion in bullet points and make sure to always keep the physical exam template EXACTLY as instructed. For the Nasal Endoscopy and Laryngoscopy sections, only use the relevant title section according to the transcript, analyzing whether a nasal endoscopy or laryngoscopy was performed. For the Audiogram section, display a detailed account of the most recent audiogram findings. ------------------------------------------------------------------------------------------------------------------------- Podiatry Prompt Generate a podiatry SOAP note. Do not use *. Generate detailed SUBJECTIVE findings focus on the CC of the patient, specifically regarding his wound and chronic disease state. Use NLDOCAT to create a detailed description of the pain or CC by the patient and divide the different CC into paragraphs depending on problems talked about during this visit. Reconcile the medications, noting any outstanding problems. Include a section Review of Systems (ROS), in the SUBJECTIVE section. Generate extremely comprehensive OBJECTIVE findings during the physical exam. Focus on the location wounds and compounding factors. Include these sections in the Objective findings talked about during visit. DERMATOLOGICAL EXAM: ORTHOPEDIC EXAM: VASCULAR EXAM: NEUROLOGICAL EXAM: LYMPHATIC EXAM: Generate the list of the current ASSESSMENT/DIAGNOSIS from the visit. Generate extremely comprehensive PLAN and design a Clinical Plan of Care for each CC or assessment and explain the reasoning behind it using the information from the provided in this exam. Generate DIFFERENTIAL DIAGNOSES and explain the reasoning behind them using the information from the provided in this exam. Highlight any new PRESCRIPTION written for during this exam in a separate section. Highlight any new ORDER written for during this exam in a separate section, like labs or imaging. Describe the PROCEDURE section in detail from the audio file, include and tests, studies, or imaging performed in the office. Highlight any REFERRALS written for during this exam in a separate section. I'd like to see thorough explanations for each intervention, educational material that might be provided to the patient, as well as the rationale for each step in the treatment plan from the provided exam with the patient. Highlight when the patient was instructed to return to the office and what will be the reason for the follow-up visit. From the provided transcript. ------------------------------------------------------------------------------------------------------------------------- Psychiatry Prompt (This will only work using GPT-4-32K) Please use this psychiatric template for the encounter and do not use the client's name: TEMPLATE: E/M: BASED ON MDM PSYCHOTHERAPY TIME IN: can you please input a time here that is 40 minutes after the appointment time PSYCHOTHERAPY TIME OUT: can you please input a time here that is 60 minutes after the appointment time MEETING TYPE: please list if this in person or virtual CC: the client's own words "" HPI: Please create a summary paragraph of the client with the included information in a well-written paragraph format with the following information. Client Introduction: This is a [Client's Age]-year-old [Client's Gender] client, who has presented for an initial psychiatric evaluation. (Psychiatric History:) [Past psychiatric diagnoses and when they were diagnosed or state 'The client has no previous psychiatric diagnosis, though they have been displaying symptoms of [possible diagnosis (anxiety, depression, etc.)] for roughly [time length].'] (Referral:) [If the client was referred, mention 'The client was referred by [person/organization.']. (Hospitalizations:) [State any previous hospitalizations for psychiatric reasons and suicide attempts/self-injurious behavior, or mention 'The client has had no prior psychiatric hospitalizations nor revealed any suicidal attempts or self-injurious behavior in the past.' Or a combination of the two possibilities based on client information] (Medical and Substance Use History:) [Include any relevant past medical history tied to psychiatric conditions, or specify] [If relevant, mention 'The client has a history of substance use disorder relating to [substances].'] (Prior and Current Treatments:) [Detail the client's previous psychiatric treatments, outcomes, current therapies, current mental health providers, or state 'The client has not undergone any prior psychiatric treatments and currently has no mental health providers.'] (Medications:) [If applicable, discuss 'The client is currently on [names and dosages of medications].'] [Share the effectiveness of these medications and any side effects or denote 'The client reports no significant side effects from the medications or treatments.'] [Indicate the adherence level or state 'The client has demonstrated high adherence to the prescribed dosage.'] [If the client is medication-free, state 'Presently, the client is not taking any medications for psychological health concerns.'] Remember to fill in the brackets with the relevant information. If the paragraph doesn't apply to the client, you can simply omit it from the final draft. Write the History of Present Illness (HPI) of an initial psychiatric evaluation for the following client. Write in a narrative (style, integrating the details according to the OLD CARTS Mnemonic) (Onset, Location, Duration, Character, Associated Symptoms, Radiation, Timing, Severity) within the narrative without breaking it down into separate points. If any part of the OLD CARTS information is missing, simply omit it and include only the information that was given. (Psychiatric system(s) and symptoms) Provide a narrative description of the current condition(s), (for example mood), including details about onset, location, duration, character, associated symptoms, radiation, timing, severity, modifying factors, and context, without breaking them down into separate points or including unnecessary details. If any part of this information is missing, simply omit it. Do not signify or note the possible diagnosis, this is not the assessment but is still part of the HPI and should only be covering the information gathered, the subjective information. Please make this into a NEW PARAGRAPH. [Cover any current psychosocial stressors and the effect that it is having on work/social/family life etc.] [Add a sentence covering safety like “The client denied any current thoughts or intent of harm to self or others, compulsive or intentional self-injury or mutilation, auditory/visual hallucinations, delusions, and feelings of paranoia”] Please edit this sentence to reflect the information for this client. Note: Ensure that the content is specific to the individual client and that the OLD CARTS details are seamlessly woven into the narrative, without separating them or using subheadings. Include only the details that are relevant and provided for the specific client, omitting any unnecessary or missing information from the provided transcript. Remember to fill in the brackets with the relevant information. REVIEW OF SYMPTOMS: All symptoms discussed and necessary information for a DSM 5 diagnosis should be listed under each category below under review of systems, if applicable. If a diagnosis is possible and a category is not listed below, please create the category. (please use the outline below) (*)APPETITE: (Report changes in appetite, either increased or decreased, if it is grossly normal, normal for them, overall description of their eating habits and patterns) (*)SLEEP: (Note disturbances in sleep patterns, how many hours of sleep they are getting, if they have trouble falling asleep, staying asleep, mid night awakenings and falling back asleep, if they state they have good and restful sleep, note however they talk about their sleep) (*)DEPRESSION: [note Denies symptoms of depression if there are no symptoms] Mood: (Include symptoms related to mood such as sadness, irritability, mood swings, etc.) Interest: (Note any loss of interest or pleasure in activities, including specific activities etc.) Energy (Include symptoms of fatigue, low energy, or lethargy etc.) Eating (Report changes in appetite, either increased or decreased etc.) Sleep (Include sleep disturbances such as insomnia or hypersomnia etc.) Self-esteem (Include feelings of worthlessness or excessive guilt etc.) Focus (Note issues with concentration or decision-making etc.) Movement (Report psychomotor agitation or retardation etc.) Suicide (Include suicidal ideation, plans, or attempts etc.) (*)MANIA: [note Denies symptoms of mania if there are no symptoms] Mood (Note elevated, expansive, or irritable moods, etc.) Energy (Include increased energy or hyperactivity, etc.) Speech (Note rapid or pressured speech., etc.) Sleep (Include reduced need for sleep etc.) Self-esteem (Note grandiose or inflated self-esteem etc.) Behavior (Include risky or impulsive behaviors etc.) Thought (Note racing thoughts or flight of ideas etc.) (*)ANXIETY: [note Denies symptoms of anxiety if there are no symptoms] Worry (Include excessive worrying or ruminative thoughts etc.) Restlessness (Note feelings of nervousness or agitation etc.) Energy (Report fatigue or low energy etc.) Mood (Include irritability or mood swings etc.) Tension (Note muscle tension or physical discomfort etc.) Fears (Include specific or generalized fears and phobias etc.) Focus (Report difficulty in concentration etc.) Sleep (Note disturbances in sleep patterns etc.) SOCIAL ANXIETY: Fear (Include fear or apprehension about social situations etc.) Avoidance (Note avoidance behaviors related to social situations etc.) Sweat (Include symptoms of excessive sweating etc.) Tremble (Note shaking or trembling in social context etc.) Focus (Include heightened self-consciousness or excessive worrying about social performance etc.) EATING DISORDERS: Eating (Note any abnormal eating habits like bingeing, restricting, etc.) Weight (Report significant weight changes or concerns etc.) Body Image (Include perceptions or attitudes toward body image etc.) Control (Note feelings of lack or gain of control over eating etc.) Exercise (Include excessive or compulsive exercise behaviors etc.) PMDD (PREMENSTRUAL DYSPHORIC DISORDER): Mood (Include mood swings, irritability, or emotional lability etc.) Irritability (Note heightened irritability or mood swings etc.) Tension (Include symptoms of stress or tension etc.) Eating (Note changes in appetite etc.) Sleep (Include any sleep disturbances etc.) Physical (Report physical symptoms like bloating, breast tenderness, etc.) PANIC: [note Denies symptoms of panic if there are no symptoms] Fear (Include sudden and intense fear or discomfort etc.) Heart (Note palpitations or accelerated heart rate etc.) Sweat (Include symptoms of sweating etc.) Tremble (Note shaking or trembling etc.) Breath (Include shortness of breath or feeling smothered etc.) Chest (Report chest pain or discomfort etc.) Stomach (Include symptoms like nausea or abdominal distress etc.) Control (Note feelings of losing control or impending doom etc.) OCD: Thoughts (Include obsessive thoughts or intrusive ideas etc.) Actions (Note compulsive behaviors or rituals etc.) Fear (Include fears that drive obsessive thoughts etc.) Daily Life (Report impact on daily functioning and quality of life etc.) (*)TRAUMA: [note Denies symptoms of trauma if there are no symptoms] Memories (Include intrusive memories or flashbacks etc.) Avoidance (Note avoidance of reminders or emotional numbness etc.) Mood (Include negative mood or emotional states etc.) Alert (Report hyperarousal or heightened alertness etc.) ADHD: Attention (Note symptoms of inattention such as Endorses failing to give attention to detail or makes careless mistakes, difficulty sustaining attention in tasks or play activities, does not seem to be listening when spoken to, does not follow through on instructions and fails to finish schoolwork, chores, workplace duties, difficulty organizing tasks and activities. Avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort in. Loses things necessary for tasks or activities, easily distracted by extraneous activities, forgetful in daily activities, etc.) Activity (Include hyperactivity symptoms such as Fidgets with or taps hands or feet or squirms in seat, leave seat in situations when remain seated is expected, runs about or climbs in situations where it is inappropriate, unable to play in leisure activity quietly, on the go as if driven by a motor, talks excessively, blurts out answers before a question has been completed, difficulty waiting his or her turn, interrupts or intrudes on others, etc.) SUBSTANCE USE: Substance (Specify the type of substance used.) Frequency (Note the frequency and amount of substance use.) Impact (Report the impact on daily life and responsibilities.) Withdrawal (Include any symptoms of withdrawal.) Tolerance (Note increasing amounts needed for desired effects.) PSYCHOSIS: Hallucinations (Specify the nature of hallucinations, auditory, visual, etc.) Delusions (Note false beliefs, such as paranoia or grandiosity etc.) Thinking (Include disorganized or incoherent thought processes etc.) If the above categories or diagnosis/don't apply to the client, you can simply omit it from the final draft unless it is noted that it must be on the final draft with a *. If there is a diagnosis that is missing or that needs to be added due to the client’s systems, please add this. REVIEW OF SYSTEMS: use this header for this section and remember to fill in the brackets with the relevant information. If it does not apply to the client, you can simply omit the information from the final draft. Remember to fill in the brackets with the relevant information. If it does not apply to the client, you can simply omit the system from the final draft. If none apply to the client, state “Within normal limits.” General: [Description, details, fatigue, weight change, fever, chills, night sweats etc.] Neurological: [Symptoms, triggers, any history of an ongoing neurological issue] Endocrine: [Symptoms, hormonal details, history of diabetes or any ongoing endocrine issue] Cardiovascular: [Symptoms, heart details, history of HTN, high cholesterol, heart issues, palpitations etc.] Respiratory: [Symptoms, triggers, history of asthma or sleep apnea] Gastrointestinal: [Symptoms, digestive details, appetite issues, nausea, vomiting, diarrhea] Genitourinary: [Symptoms, urinary] Gynecological: [Symptoms, reproductive details] Skin: [Symptoms, dermatological details, medical history of skin issues] Musculoskeletal: [Symptoms, triggers, medical history of issues, or current issues with ROM etc.] Hematologic/Lymphatic: [Symptoms, blood/lymph details] PAST PSYCHIATRIC HISTORY: use this header for this section and remember to fill in the brackets with the relevant information. If it does not apply to the client, you can simply omit the information from the final draft. [Previous Diagnosis] [When] [By who] [Previous Psychiatrist or Nurse Practitioner or state if no previous provider] [Previous counselor or therapist when and for how long] [when] [for how long] [Current counselor or therapist when and for how long or if no current or previous] [for how long] [started with this counselor or provider when] [Type of therapy] [other Treatments] [Hospitalizations or state denies/none] [if so, when and for how long?] [why] [Suicide attempt/s or state denies/none] [When] [How] [Self-harm or state denies/none] [When] [How] [Suicidal or homicidal thoughts or behaviors or state denies/none] PREVIOUS PSYCHIATRIC MEDICATIONS: use this header for this section and remember to fill in the brackets with the relevant information. If it does not apply to the client, you can simply omit the information from the final draft. [Previous Psychiatric Medication] [Dosage] [Route of Administration] [Frequency] [Compliance] [Side effects] [Efficacy] [why was this med stopped] [when was this med taken or how long was the client been on it] [Previous Psychiatric Medication] [Dosage] [Route of Administration] [Frequency] [Compliance] [Side effects] [Efficacy] [why was this med stopped] [when was this med taken or how long was the client been on it] CURRENT PSYCHIATRIC MEDICATIONS: use this header for this section and remember to fill in the brackets with the relevant information. If it does not apply to the client, you can simply omit the information from the final draft. List all Current psychiatric medications. [Medication Name] [Dosage] [Route of Administration] [Frequency] [Compliance] [Side effects] [Efficacy] [when was this med started or how long has the client been on it] PAST MEDICAL AND SURGICAL HISTORY: use this header for this section and remember to fill in the brackets with the relevant information. If it does not apply to the client, you can simply omit the information from the final draft. Medical history - [MEDICAL CONDITIONS or none] [also note "denies history of any head injuries, seizures, or cardiac problems" if they are not stated in the medical history] Surgical history - [SURGICAL HISTORY or none] Last Physical Examination: [PCP] [PCP Number] [LAST PHYSICAL EXAM] Last menstrual cycle: [Birth control pills/tubes tied/other forms of contraception: Discussed the effects of medications on pregnancy and advised on contraception while on medications] SUBSTANCE USE HISTORY: use this header for this section and remember to fill in the brackets with the relevant information. If it does not apply to the client, you can simply omit the information from the final draft. [Substance use/abuse] [what substance] [how much] [last used] (specifically alcohol, tobacco, or illicit drugs. “Denies alcohol, tobacco, or illicit drug use” unless not denied) ALLERGIES: use this header for this section and remember to fill in the brackets with the relevant information. [ALLERGIES] CURRENT MEDICATIONS: use this header for this section and remember to fill in the brackets with the relevant information. If it does not apply to the client, you can simply omit the information from the final draft. List all of the current medications the client is taking, excluding the psychiatric medications. [Medication Name] [Dose] [Route] [Frequency] [what it is for] [Medication Name] [Dose] [Route] [Frequency] [what it is for] FAMILY PSYCHIATRIC HISTORY: use this header for this section and remember to fill in the brackets with the relevant information. If it does not apply to the client, you can simply omit the information from the final draft. List all of the family psychiatric illness history. [who/family member] [history of suicide] [diagnosis/es] [current treatment if known] [treatment effective?] [who/family member] [history of suicide] [diagnosis/es] [current treatment if known] [treatment effective?] FAMILY SUBSTANCE ABUSE HISTORY: use this header for this section and remember to fill in the brackets with the relevant information. If it does not apply to the client, you can simply omit the information from the final draft. List all of the family psychiatric illness history. [who/family member] [substance used] SOCIAL HISTORY: use this header for this section and remember to fill in the brackets with the information. Each item below should be included. Living arrangement: [LIVING ARRANGEMENT] Occupation: [OCCUPATION] Marital status: [MARITAL STATUS] Children: [CHILDREN] Support system: [SUPPORT SYSTEM] Abuse/trauma history: [ABUSE OR TRAUMA HISTORY] Gender Identity: [GENDER IDENTITY] Sexual orientation: [SEXUAL ORIENTATION] Religious Affiliation: [RELIGIOUS AFFILIATION] Legal issues: [LEGAL ISSUES] MENTAL STATUS EXAM: use this header for this section and remember to fill in the MSE as best as possible with the given information. Appearance: (if this is not stated to be abnormal or cannot be identified as abnormal from the script, put a description of a normal value. Appears to be stated age and is dressed appropriately etc.) Mood: (if this is not stated to be abnormal or cannot be identified as abnormal from the script, put a description of a normal value) Affect: (if this is not stated to be abnormal or cannot be identified as abnormal from the script, put a description of a normal value) Speech: (if this is not stated to be abnormal or cannot be identified as abnormal from the script, put a description of a normal value) Thought Process: (if this is not stated to be abnormal or cannot be identified as abnormal from the script, put a description of a normal value) Thought Content: (if this is not stated to be abnormal or cannot be identified as abnormal from the script, put a description of a normal value) Perceptions: (if this is not stated to be abnormal or cannot be identified as abnormal from the script, put a description of a normal value) Memory: (if this is not stated to be abnormal or cannot be identified as abnormal from the script, put a description of a normal value) Judgment: (if this is not stated to be abnormal or cannot be identified as abnormal from the script, put a description of a normal value) Insight: (if this is not stated to be abnormal or cannot be identified as abnormal from the script, put a description of a normal value) Attention and concentration: (if this is not stated to be abnormal or cannot be identified as abnormal from the script, put a description of a normal value) Impulse control: (if this is not stated to be abnormal or cannot be identified as abnormal from the script, put a description of a normal value) ASSESSMENT: use this header for this section and remember to fill in the brackets with the relevant information. [List the psychiatric diagnosis/es of the client with its modifiers and the ICD 10 codes] [List the psychiatric billing codes for this 60-minute encounter with at least 20 minutes of therapy] [Baseline GAD 7]: please put the score and today’s date [Baseline PHQ 9]: please put the score and today’s date Write the assessment portion of this initial psychiatric evaluation in paragraph form. Each diagnosis should be it’s own paragraph. Please use the given client information to come up with all of the possible diagnosis/es for the client and any rule-out diagnosis. [DIAGNOSIS, list the diagnosis]: [include all symptoms that confirm the diagnosis and make into an assessment paragraph that shows that the criteria is met for the DSM 5 diagnosis, but this does not have to be stated, or explain that this was a prior diagnosis by a previous provider and further assessment is needed or whatever is applicable per the information given.] PLAN: [describe the plan for the diagnosis, counseling, therapy, medications, supplement etc. describe education about the diagnosis and include client teaching about this diagnosis] [In this paragraph, Discuss medical necessity and risk assessment. Discuss safety plan, if necessary.] [write a sentence or two about the possible plans in the future based off the client’s outcomes like, plan to possibly increase dose, decrease dose, change med, add a med etc if not doing it at this appt.] [Note here if PMP was checked] Remember to fill in the brackets with the relevant information. If it does not apply to the client, you can simply omit the information from the final draft. TREATMENT PLAN: Use this header for this section and remember to fill in the brackets with the relevant information. if a thorough treatment plan is not given, please suggest one based off the given client encounter, or add to what has been given. Put this in list form with a “-“ in front of each. List the planned interventions [including and starting with medications and dosages or supplements] [Start/Continue/Discontinue/Increase/Decrease/Begin to taper/Continue to Taper ______][Medication Name or supplement name] [Dose] [Route] [Frequency] [if the “Medication Plan” or “Supplement Plan” Includes “Start” a medication, include a sentence about the client being educated on the medication. For example, if they are starting sertraline, please list, common side effects for the medication, what to look out for with the specific medication, when it is suggested to take the medication, with or without food if applicable, if the client is a female, add that it was discussed about pregnancy and the use of contraceptive. Also note any black box warnings for the medication, the effects if it is mixed with alcohol and any other necessary client teaching for the specific medication.] Please note here if the client is to Continue current medication regimen and list the medications [CURRENT PSYCHIATRIC MEDICATIONS:], if applicable. [List any non-pharmaceutical treatments, and other considerations such as lab tests, or lifestyle recommendations, this can be on multiple lines] [Create a sentence for the treatment plan of anything else that the client has been noted to have been educated on, or should be educated on] [Discuss therapy plan here, if the client is in therapy, ex. Continue therapy with current counselor/therapist ___ or put name if it is available and add how often they are seeing each other if this is known, or note if they are to be looking for a therapist, or whatever the status of their therapy is] [Describe any additional follow-up requirements concisely] Follow-up: Next appointment: [Provide details for the next appointment] Please maintain brevity and clarity, focusing on essential details tailored to the client's condition and needs from the provided transcript. Remember to fill in the brackets with the relevant information. ------------------------------------------------------------------------------------------------------------------------- Hospice Please generate a medical progress note using the following template. NAME: GENDER: DOB: DATE: WGT: HEIGHT: BMI: LMAC: CHIEF COMPLAINT: HPI: ALLERGIES: Other: Review of medications: PAST MEDICAL HISTORY: [ ] APPENDECTOMY [ ] CHOLECYSTECTOMY [ ] TAH [ ] OTHER [ ] UNKNOWN Social History: [ ] TOBACCO [ ] ETOH [ ] DRUGS [ ] IMMUNIZATION STATUS: [ ] OTHER [ ] UNKNOWN Family History: MOTHER: [ ] ALIVE [ ] DECEASED: [ ] UNKNOWN FATHER: [ ] ALIVE [ ] DECEASED: [ ] UNKNOWN REVIEW OF SYSTEMS: GEN: [ ] NEGATIVE [ ] ANOREXIA [ ] OBESE [ ] FEVER [ ] FATIGUE [ ] OTHER: HEENT: Ears: [ ] NEGATIVE [ ] PINNAE INTACT [ ] TM CLEAR [ ] OTHER: EYES: [ ] NEGATIVE [ ] SCLERA CLEAR [ ] DECREASED VISION [ ] OTHER: NOSE: [ ] NEG [ ] DISCHARGE [ ] OTHER: THROAT: [ ] NEGATIVE [ ] PAIN [ OTHER: MOUTH: [ ] LESION [ ] OTHER: CARDIOVASCULAR [ ] NEGATIVE [ ] CHEST PAIN [ ] PALPITATION [ ] DOE [ ] EDEMA [ ] OTHER: RESPIRATORY:  NEGATIVE  WHEEZING [ ] SOB [ ] COUGH [ ] OTHER: GASTRO: [ ] NEGATIVE [ ] DIARRHEA [ ] CONSTIPATION [ ] PAIN [ ] HEARTBURN [ ] OTHER: GENITOURINARY: [ ] NEGATIVE [ ] HEMATURIA [ ] DYSURIA [ ] INCONTINENT [ ] OTHER: MUSCULOSKELETAL: [ ] NEGATIVE [ ] JOINT/MUSCLE PAIN [ ] BACK PAIN [ ] OTHER: SKIN: [ ] NEGATIVE [ ] MASSES [ ] RASH [ ] ULCERS [ ] OTHER: NEUROLOGICAL: [ ] NEGATIVE [ ] SYNCOPE [ ] SEIZURES [ ] TREMORS [ ] HEMIPLEGIA [ ] OTHER: PSYCHIATRY: [ ] NEGATIVE [ DEPRESSION [ ] ANXIETY [ ] MEMORY LOSS [ ] OTHER: HEMAT/LYMPH: [ ] NEGATIVE [ ] BRUISES [ ] BLEEDING [ ] ADENOPOTHY [ ] OTHER: PERIPHERAL VASCULAR: [ ] NEGATIVE [ ] VERICOSE VEINS [ ] CLAUDICATION [ ] OTHER: PHYSICAL EXAMINATION: BP: Left Wrist HR: RR: TEMP: O2: PAIN: GEN: Well developed [ ] Well-nourished [x ] Non-acute distress [ ] Cachexia HEENT: [ ] PERRL [ ] EOM [ ] Normal conjunctive  TMs clear [ ] NECK: [ ] No JVD [ ] No carotids bruits [ ] Thyroid WNL [ ] No masses Palpated/Observed LUNGS: [ ] CTA [ ] Expiratory wheezes [ ] Rhonchi [ ] Inspiratory crackles [ ] Diminished HEART: [ ] PMI SR Rhythm: [ ] Regular- brady [ ] Irregular [ ] Sounds: S1x S2x systolic murmur ABD: EXTS: 1+ Pulses: NEURO: AMBULATORY DEVICE: [ ] Cane [ ] Walker [ ] Wheelchair or heavy assist  Bedbound DIET: ASSESSMENT: PLAN: [ ] Medication side effects explained [ ] Fall precautions [ ] Home Health Care Services [ ] Use Geri chair or WC [ ] Bed bound [ ] Patient noncompliant: [ ] Treatment [ ] Other: [ ] Discussed with staff plan above. Patient was seen today for: ATTESTATION: I composed this note based on the evaluation of the patient today, and review of the chart and discussion with "Doctor X" and the patient. The clinical findings are being submitted for the Medical Director's review for determining eligibility for continuing hospice care. ------------------------------------------------------------------------------------------------------------------------- Veterinary Please generate a medical progress note using the following template. Subjective: Patient Name: _____________ Signalment: _____________ PRESENTING COMPLAINT: _____________ Hx: Relevant clinical signs and progression summary: _____________ Energy/ Appetite/ Thirst/ Sleep/ Cough/ Sneeze/ Vomiting/ Diarrhea/ Urination activities, Mobility: _____________ Active Medical Diagnosis: _____________ Past Medical History including resolved Dx: _____________ Medications: Current: _____________ Within the past 30 days: _____________ Diet: Type: _____________ Size: _____________ # meals/day: _____________ Objective: Physical Exam Findings: General: _____________ EYES: _____________ EARS: _____________ NOSE: _____________ ORAL CAVITY: _____________ THROAT: _____________ RESPIRATORY: _____________ CARDIOVASCULAR: _____________ ABDOMEN: _____________ MUSCULOSKELETAL: _____________ NERVOUS SYSTEM: _____________ LYMPHATIC: _____________ INTEGUMENT: _____________ UROGENITAL: _____________ RECTAL/ANUS: _____________ ------------------------------------------------------------------------------------------------------------------------- Frameworks Create a framework of questions for a physician that is interviewing a [write patient parameters here] with [write clinical condition here]
- How Your Recording Device Impacts AI Generated Clinical Documentation
In the technologically-driven world of medicine, AI plays an increasingly pivotal role in clinical documentation. One of the often-overlooked factors that can heavily influence the quality of AI-generated documentation, such as SOAP notes or H&P notes, is the recording device used. The quality of the audio input determines the precision of the output. Table of Contents The Connection Between Recording Quality and AI Documentation Why Device Quality Matters The Apple Edge: A Benchmark in Audio Recording Strategies to Improve Recording Quality Making the Case for an iPhone Upgrade to your Boss. Concluding Remarks 1. The Connection Between Recording Quality and AI Documentation The efficacy of AI transcription lies in its ability to accurately interpret audio data. Clearer audio means more accurate transcriptions, and thus, more reliable clinical documentation. A poor recording can result in misunderstood phrases or missed information, leading to inaccuracies that could impact patient care. 2. Why Device Quality Matters Superior Microphone Sensitivity: High-quality devices capture nuanced vocal tones, reducing the chances of misinterpretation. Noise Cancellation Features: Premium devices often come with noise-canceling features that isolate the speaker's voice, ensuring background noises don't interfere with the recording. 3. The Apple Edge: A Benchmark in Audio Recording Apple products, renowned for their design and functionality, also stand out in the realm of audio recording. Devices like the iPhone or MacBook: Offer Crystal Clear Audio: Apple's built-in microphones are engineered to capture clear and detailed sound. Integrate Advanced Noise Cancellation: Apple's software and hardware work in tandem to minimize ambient noise. For those serious about achieving the best AI-generated clinical documentation, Apple products are a worthy investment. 4. Strategies to Improve Recording Quality To achieve the best transcription results: Isolate the Environment: Record in a quiet space, away from background noises or disturbances. Place the Device Strategically: Position the device close enough to capture the speaker's voice but not so close that it captures distorted sound. Regularly Test and Clean Your Device: Ensure your microphone works correctly and is free from dust or obstructions. 5. Making the Case for an iPhone Upgrade to your Boss. Investing in optimal technology isn't just about personal convenience or embracing the latest trends. In the realm of medical practice, it directly pertains to patient care quality. Therefore, for medical professionals aiming to harness the best of AI in clinical documentation, requesting the best tools becomes not only a matter of preference but also a necessity. Why the iPhone Makes a Difference: Quality Assurance: As highlighted, the superior recording capabilities of the iPhone ensure the most accurate AI transcription. Efficiency: With faster processing speeds and intuitive interfaces, tasks get completed more swiftly, allowing more time for patient care. Data Security: Apple's commitment to user privacy and data security is unparalleled, ensuring that patient data remains confidential and safe from potential breaches. A Legitimate Request: Medical professionals can thus present a legitimate case to their supervisors or hospital administrators for upgrading to an iPhone. By emphasizing its direct impact on improving patient outcomes and ensuring efficient, accurate clinical documentation, it becomes less of a personal request and more of a strategic investment in patient care. Such a forward-thinking approach not only showcases the professional's commitment to excellence but also underscores the broader perspective of prioritizing patient welfare. Conclusively, when navigating the realms of advanced technology in healthcare, it's crucial to recognize the importance of the tools used. With Apple's proven track record, the iPhone emerges not just as a luxury but as an essential tool in the contemporary medical toolkit. 6. Concluding Remarks In the world of AI clinical documentation, the adage "garbage in, garbage out" holds true. The quality of the input— in this case, the audio recording—directly influences the quality and accuracy of the output. By investing in top-tier recording devices and adopting sound recording practices, medical professionals can significantly enhance the reliability of their AI-generated clinical notes.
- How to Reduce AI Hallucinations in AI Generated Clinical Documentation
AI hallucinations, where AI produces non-factual information, pose challenges in clinical documentation. To mitigate this: Custom Research Integration: Incorporate individual doctors' trusted research studies into AI training, ensuring the AI's output matches their specific knowledge base and preferences. Address Doctor Biases: Recognize that each doctor has unique perspectives on medical research and trusts different sources. Allowing AI customization based on their biases ensures better alignment with their clinical approach. Use Healthcare-Specific AI Models: Implement models like Bio Clinical BERT, which are designed for medical contexts and are less prone to hallucinations due to their training on relevant medical literature. Incorporating these strategies can enhance the accuracy and reliability of AI-generated clinical documentation. Table of Contents Understanding AI Hallucinations in Clinical Contexts The Role of Custom Research Studies in AI Training Doctor Biases: Individualized Knowledge Bases The Power of Healthcare-Specific Models Concluding Thoughts 1. Understanding AI Hallucinations in Clinical Contexts AI hallucination refers to the phenomenon where the AI generates information that isn't based on factual input or training data. In clinical documentation, this can be especially problematic, leading to potential misdiagnoses or inappropriate treatment suggestions. 2. The Role of Custom Research Studies in AI Training Personalized Learning: Every doctor has their trusted research sources and studies they lean on. Integrating these studies into AI training can tailor the AI's output to match a doctor's preferences and trusted knowledge base. Minimizing Generalization: Relying solely on generalized AI models can increase the risk of hallucination. But by adding custom research, AI can produce more relevant and accurate clinical plans. 3. Doctor Biases: Individualized Knowledge Bases Every doctor is unique, with their own perspectives on medical research. They often: Trust Different Sources: What one doctor views as a credible source, another might question. Interpret Data Differently: The same research can be interpreted in myriad ways, leading to varied clinical approaches. Allowing doctors to customize AI knowledge bases according to their scientific biases ensures that the AI's recommendations are more aligned with each doctor's clinical approach, thereby improving trust and adoption. 4. The Power of Healthcare-Specific Models Models like Bio Clinical BERT have been designed specifically with healthcare in mind. They: Are Trained on Relevant Data: Such models are exposed to vast amounts of medical literature, ensuring their outputs are more clinically relevant. Reduce Hallucinations: By nature, these models are less prone to generating information that doesn't align with established medical knowledge. Integrating such models can significantly elevate the reliability of AI-generated clinical documentation. Concluding Thoughts: How to Reduce AI Hallucinations While the integration of AI in clinical documentation offers transformative potential, it's essential to be wary of the risks. By allowing doctors to incorporate their trusted research studies and biases, we can ensure AI outputs that are both accurate and personalized. Furthermore, leaning on healthcare-specific AI models can drastically reduce the risk of hallucinations, ensuring that AI remains a trustworthy ally in the medical field.
- What is an AI Medical Scribe? Understanding the Future of Healthcare Documentation
An AI Medical Scribe is an advanced artificial intelligence system designed to listen to doctor-patient interactions and transcribe the conversation into structured medical records in real-time, using technologies like Natural Language Processing (NLP). It automates the documentation process, allowing doctors to focus more on patient care. Table of Contents Introduction to AI in Healthcare Definition of an AI Medical Scribe How AI Scribes Work Benefits of AI Medical Scribes Challenges and Considerations The Future of AI Scribing in Medicine 1. Introduction to AI in Healthcare Before diving into AI medical scribes, it's essential to understand AI's broader role in healthcare. From diagnostics to treatment recommendations, AI systems have increasingly been aiding medical professionals to provide better patient care. Their potential in handling large volumes of data and deriving insights has been pivotal in medical research and patient care. 2. Definition of an AI Medical Scribe An AI medical scribe is an advanced AI system trained to listen to doctor-patient interactions and transcribe the conversation into structured medical records. Unlike traditional human scribes, who manually note down patient interactions, AI scribes use Natural Language Processing (NLP) to understand and record the consultation in real-time. 3. How AI Scribes Work Natural Language Processing (NLP): At the core of AI scribes is NLP, which helps the system to understand human language, interpret context, and record relevant medical information. Voice Recognition: AI scribes are designed to recognize different voices, accents, and terminologies. This allows for seamless transcriptions, even in noisy environments. Data Integration: After transcribing, the AI scribe integrates the data with the hospital's Electronic Health Record (EHR) system, ensuring that patient records are up-to-date. 4. Benefits of AI Medical Scribes Efficiency: Doctors can focus on patient care without the distraction of note-taking. This leads to more engaged consultations and reduced consultation times. Accuracy: AI systems minimize human error, ensuring that patient records are accurate and comprehensive. Cost-effective: While there's an initial investment, in the long run, hospitals can reduce costs associated with hiring and training human scribes. Real-time Updates: Instant transcription means patient records are updated in real-time, aiding immediate decision-making. 5. Challenges and Considerations Data Privacy: With AI systems recording patient interactions, ensuring data privacy and security is paramount. Training and Adaptation: Like all AI systems, medical scribes require training and might face challenges in understanding diverse accents or terminologies initially. Reliability: Ensuring that the AI system is reliable and doesn't miss out on critical information is crucial. 6. The Future of AI Scribing in Medicine As technology evolves, it's expected that AI medical scribes will become more sophisticated, offering not just transcription services but also insights based on the collected data. Integrating AI scribes with other AI-powered diagnostic tools can revolutionize how doctors approach patient care. Conclusion The advent of AI medical scribes signifies a shift towards more efficient and patient-centric healthcare. By relieving medical professionals from administrative tasks, AI allows them to channel their skills and expertise where they're needed most: patient care. As with all technology, it's essential to weigh the benefits against potential challenges. Still, there's no denying that AI scribes represent a step forward in the modernization of healthcare.