Ultimate AI Note Template Guide

What is a Custom AI Note Template?

Custom AI Note Templates are specifically designed to enhance the functionality of AI Scribe and Voice Chart. These templates allow you to define a structure, ensuring the generated notes follow your specified format and style preferences.

Why Are Custom AI Note Templates Useful?

Custom instructions let you guide the AI on how to write your notes. Every clinician has a unique way of documenting, and AI Scribe adapts to your preferences rather than imposing a predefined format. Chartnote stands out by enabling users to create notes tailored to their style, providing unparalleled flexibility.

How Do I Create a Custom AI Note Template?

For instance, you can instruct the AI to write in the style of an ophthalmologist, using standard abbreviations without including definitions in parentheses. For example, the AI will write IOP instead of IOP (Intraocular Pressure). You can also specify how the AI should refer to your patient—by pronoun, first name, or last name—based on your preference.

Here’s how you can customize your templates:

• Format the HPI as a single, comprehensive paragraph, including all pertinent details without length restrictions.

• Include vitals, labs, and imaging results.

• For patients with multiple chronic conditions, organize the HPI into problem-specific sections with subheadings (e.g., hypertension, diabetes, hyperlipidemia).

Example instructions: Organize the HPI using subheadings for each condition. Include details such as symptoms, lab results, updates, medication compliance, symptom management, and lifestyle factors like diet and exercise.

Can I Use Snippets in My Custom Template?

Currently, snippets cannot be expanded while building a Custom AI Note Template. However, you can use them after your note has been processed. Some users have requested voice commands to apply snippets during the AI Scribe recording—this exciting feature is in development.

In the meantime, you can include small templates within your section instructions. For example, in the Physical Exam (PE) section:

• Utilize the provided template and adjust it as needed to fit the specific case.

General: [No acute distress.]
Lungs: [Clear]
Cardiovascular: [Normal heart sounds. No lower extremity edema.]
Psych: [Alert and oriented x3.]
Skin: [No rashes or skin lesions.]
Neuro: [Sensation and CN II-XII grossly normal.]         

During your visit, if you mention a systolic murmur, the AI will automatically update the boilerplate template with the findings transcribed.

What Else Can Custom AI Note Templates Do?

Chartnote’s AI understands complex instructions. Here are some favorite use cases:

Assessment Section

• List all problems and include their ICD-10 codes.

• For ACO settings, focus on HCC coding to ensure the note reflects accurate Risk Adjusted Factor (RAF) scores.

Hospital Documentation

• Summarize the patient’s presentation and diagnosis in one or two sentences.

Example: This is a 65-year-old male presenting with fever and cough, diagnosed with bacterial pneumonia.

Plan Section

• Use a problem-based approach with clear divisions by medical problem.

Example: List problems using hashtags (#) instead of numbers.

• For ICU settings, use a systems-based approach with detailed subsections.

• Ensure documentation supports billing levels by adhering to MEAT principles (Monitored, Evaluated, Assessed, Treated).

Adding Subsections

You can create subsections within any section to ensure the AI follows a structured format. For example, a psychiatrist using the DSM-IV multi-axial approach might define:

Diagnosis
Axis I:
Axis II:
Axis III:
Axis IV:
Axis V:        

Billing Section

A Billing section can be added to suggest ICD-10 and CPT codes. With this feature you can select the visit setting (inpatient, outpatient, etc.) and type (initial, follow-up, etc.). Particularly important for E/M codes.

Disable this section if it’s not relevant to your workflow.

Chartnote Doc Wizard

If you prefer not to write detailed instructions yourself, the Chartnote Doc Wizard can help. Available through ChatGPT (account required), this tool generates template suggestions based on your specialty and sample clinical notes (without PHI). Simply describe your specialty and provide an example note for guidance.

Take Control of Your Documentation Today

Custom AI Note Templates empower you to create notes tailored to your unique documentation style, ensuring accuracy, clarity, and efficiency. With tools like Chartnote, documentation becomes a seamless extension of patient care.