If you have some sort of medical practice, chances are you spend hours every day scribbling note, reviewing charts, and documenting patient visits.
But, as a doctor, you want to focus on practicing medicine, not doing paperwork. What if there was a way to get back two hours a day and bring your clinic into the modern age?
The answer? Clinical notes automation.
In this article, we’ll focus on:
- The basics of clinical notes automation
- The process of taking notes with an automated system
- How automating notes improves overall patient care
- How to use the best available AI tool to automate your notes
Let’s get started!
What is Clinical Notes Automation?
Clinical notes automation allows you to save time on one of the most tedious parts of running a practice - documenting patient encounters.
Instead of manually typing notes or dictating them to a medical scribe, automation handles it for you. To make things even better, it will even enter the notes into your EHR system for you too!
What exactly does clinical notes automation do?
Clinical notes automation uses tools like voice recognition, natural language processing, and machine learning to automatically generate notes from your patient interactions.
Here are what the basic steps look like:
- You dictate or record your notes after seeing a patient. You can do this on a mobile device or a desktop microphone.
- Then, your audio is automatically converted to text and formatted into a proper clinical note. Many systems can identify medical terms, abbreviations, and the overall structure of a note to create an accurate first draft.
- Then, it’s time to review your draft note and add it to your patient’s EHR. Some systems can even automatically schedule follow-up visits or order standard tests based on the content of your notes.
Using an automation solution for your clinical notes can save several hours of admin time each week.
Plus, It also leads to more detailed, consistent notes since you're dictating right after seeing the patient, avoiding having to do it from memory later in the day.
And the greatest benefit of clinical notes automation? You get to spend more time with your patients.
The process of clinical notes automation
Clinical notes automation follows a set process to get from dictation to EHR notes – and follow-ups.
Here it is:
The talking part
Many doctors and physicians find that dictating notes and reports using voice recognition software is an easy and efficient way to capture information.
Speech recognition software has come a long way, and can now quickly and accurately transcribe clinician dictation.
Doctors simply speak their notes and thoughts after seeing a patient, and the software types them out. Some systems even allow clinicians to make edits and sign off on the note directly within the software.
Remember that, in this case, it’s important to use specialized dictation software that will understand medical jargon and terminology. Any old transcription service won’t do.
But don’t worry, because we’ll get to that later!
Now comes the EHR
We probably don’t need to remind you about having comprehensive patient clinical notes in your EHR.
That’s why most state-of-the-art clinical documentation systems will now auto-populate new notes – after you sign off on them and make any appropriate edits.
They also offer automated charting features that can pull in information from previous notes, lab results, problem lists, and other areas of the patient record that can also be added to new notes.
Also, major clinical notes automation solutions offer seamless integration with major EHR systems like Epic and Cerner.
This avoids the need for that pesky double data entry (you know you hate it) and guarantees that notes are added in a consistent format.
The after: Scheduling, follow-ups, etc
The most advanced clinical notes automation systems use natural language processing to analyze the content of notes.
After, with some direction from you, they can take appropriate follow-up actions like scheduling appointments or tests, setting reminders for patient follow-up, or even alerting care teams if something more serious is going on.
So, at this point, you may be wanting to get in on the clinical notes automation action. After all, it can save you time, money, and effort.
But you need the right tool for the job, and we’ve got just what the doctor (you?) ordered.
Using Lindy for Clinical Notes Automation
Lindy is a cutting-edge AI assistant that listens, understands, transcribes, and helps you with every single part of your note-taking process.
Here’s how Lindy does it:
- Fast and accurate speech recognition understands even the most specialized terminology. You speak and Lindy types.
- Click a button, the note goes into the EHR. No more waiting, no more reprocessing. Plus, information is pulled automatically from all sources within the EHR.
- Real-time charting assistance that suggests text based on keywords spoken and data within the patient record. You can then accept, edit, or ignore these friendly suggestions.
- Lindy will learn from you. As time goes by, it becomes even more precise by understanding your speech patterns, personal abbreviations, and colloquialisms.
- Intelligent task management that alerts you and your staff to follow-up items like tests, referrals, and appointments based on details in the notes.
- Fully HIPAA compliant to protect your patients’ privacy.
Lindy helps clinicians and staff regain up to 2 hours per day – a whopping 80% reduction in time spent on notes.
Best practices for implementing clinical note automation in your practice
Regardless of which clinical note automation system you use, following these best practices will help ensure a smooth transition and allow you to bring modernization into your clinical practice.
Smart off small
Don’t try to automate your entire clinical note process in one go.
Pick one or two areas to focus on, like automating your initial patient notes or billing codes. Get familiar with the software, and then try to work your way up.
If you follow an incremental approach. you won’t get overwhelmed or make costly errors.
Trust your notes, but review them!
Once you’ve started using automated clinical notes, take time to review them before you sign off on them.
While specialized systems can provide an unparalleled amount of precision, it may take some time before the AI becomes “used” to you.
Also, some parts of your dictation may have come off less clearly, or other issues may rear their heads.
Always read through the automated notes in detail, going over every nook and cranny to make sure that they got what you said down to the letter. Then, and only then, enter them into the EHR.
Don’t get discouraged
New technology can lead to questions, issues, and frustration, even after a comprehensive trial run.
Don’t be shy about contacting technical support for your clinical notes automation system and coming to them with any problems or concerns.
You should try to work through kinks instead of going back to the pen-and-paper way of doing things.
Summing up
Clinical note automation can completely revolutionize your practice.
If you use tech to handle one of the most mind-numbing parts of your job, you'll gain back a significant chunk of your day, leaving you more time to focus on patient care and positive outcomes – and probably some positive work/life balance too!
