PracSuite AI provides several standard AI clinical note templates that cover a range of common clinical note formats in Australia. The standard AI clinical note templates include:
SOAP - Subjective, Objective, Assessment, Plan
SOAP (Brief) - Subjective, Objective, Assessment, Plan (Brief)
SOAPIE - Subjective, Objective, Assessment, Plan, Intervention, Evaluation
SOAPIE (Brief) - Subjective, Objective, Assessment, Plan, Intervention, Evaluation (Brief)
Narrative Note - Free-text narrative style
Case Note - Interactions, interventions, and plans
CHIME - Chief complaint, History, Investigation, Management, and Evaluation
Progress Note - Track the patient's progress over time
Care Plan - Outline patient needs, including the interventions and goals of care
In addition to the built-in AI Clinical Note templates, you can create your own templates to meet specific requirements or align with your organisation's clinical notes policies. Two methods are available for customisation:
Fine-Tune a Built-in AI Clinical Template
Create a Custom AI Clinical Note Template
For most users, fine-tuning a built-in AI Clinical Template is the easiest and most effective way to achieve tailored outputs. On the other hand, creating a custom AI Clinical Note Template provides the highest level of flexibility and personalisation but requires more effort and expertise. Both methods allow you to create templates that suit your unique needs.
Fine Tuning a Built-In AI Templates
To customise PracSuite's built-in templates, go to Settings > Clinical Notes > AI Clinical Templates.
Select Fine Tune Built-In Template
Enter a name for your customised template and, if needed, choose a folder to store it. Use the Access button to set which practitioners/professions can view this template.
Select a Reference Template from the dropdown list of built-in AI Clinical Note Templates. This will serve as the foundation for your custom template.
In the Default AI Fine Tune text box, type out any adjustments to guide the AI in modifying the built-in template. For example, you might add "include a differential diagnosis section" and "refer to the patient as <<Preferredname>>" to a new differential diagnosis section in the clinical note, and use the <<Preferredname>> clinical note merge field so that the Patients preferred name will be used in the clinical note.
Creating a Custom AI Clinical Note Template
Custom AI Clinical Note templates can be created in Settings > Clinical Notes > AI Clinical Templates.
Select Add Template.
Enter a name for the template and select a Folder for the template (if required). You can also use the Access button to set which practitioners/professions can view this template.
In the main section of the page, you can build your AI clinical note template.
The leading instruction is 'Create a clinical note using the following format:'
Below this, you will need to structure your template with sections and enter clear instructions for the AI regarding how it should use information collected through dictation, patient conversations or notepad transcripts to create the clinical note.
AI instructions should be entered between square brackets. For example:
[Summarise the patient’s main symptoms, their current activity level, and their treatment goals.]
AI Clinical Note template can also include patient merge fields, like <<FirstName>>, <<DateOfBirth>> etc.
AI Clinical Note Prompting Tips
If you’re new to AI prompts or haven’t used generative AI tools before, this guide will help you create effective clinical note templates.
1. What Are Prompts?
Prompts are instructions that guide the AI in generating text based on the information contained within dictation or conversation recordings. By crafting clear and specific prompts, you ensure that the AI highlights the most important information and organises it meaningfully.
2. Think of Prompts as Guides for the AI
When creating prompts, it’s helpful to ask yourself key questions about what information you want the AI to include. This reflective process will help you form precise and effective prompts that guide the AI towards generating useful content.
For example, ask yourself:
“What important details about the patient’s condition should be highlighted?”
“What key findings from the exam need to be included?”
“What changes in the patient’s condition should be noted?”
By considering these types of questions, you can develop clear, targeted prompts that direct the AI to focus on the most relevant information.
3. Use Clear and Specific Prompts
Instructions for PracSuite AI should be provided between square brackets. The clearer your instructions, the better the AI will understand what details to include.
Avoid vague prompts like “Write about the patient,” which can lead to incomplete or disorganised notes. Instead, focus on specific areas of the patient’s information that need to be summarised. Be explicit in your instructions to guide the AI effectively.
For example, you can instruct it to highlight important observations and include precise details relevant to the patient’s condition.
Instead of: “Write about the patient.”
Use: “[Summarise the patient’s main symptoms, their current activity level, and their treatment goals.]”
4. Structure the Template for Logical Flow
To ensure the AI-generated note is clear and easy to follow, structure your prompts in a logical format, such as the popular SOAP (Subjective – Objective – Assessment – Plan) format.
Subjective: Start with the patient’s own report of their symptoms, goals, or current condition.
Objective: Include practitioner observations, tests, or measurements.
Assessment: Provide the professional’s opinion based on subjective and objective findings, including prioritised problems.
Plan: Summarise the treatment plan, detailing interventions, session frequency, and any equipment needed.
By following this structure, you ensure that the note flows smoothly and that all key areas are covered.
5. Handle Missing or Irrelevant Information with Flexibility
When creating prompts, it’s important to anticipate that not all information will always be available or relevant. To avoid including irrelevant content in the final note, use conditional prompts that allow the AI to skip over certain sections when the data isn’t present. This ensures the note remains clear and concise.
For example, some sections of the clinical note may not apply in every situation:
Family or caregiver input: “[If applicable, include relevant input from the patient’s family or caregiver.]”
Social history: “[If available, summarise the patient’s relevant social history, including occupation or living situation.]”
Specific test results: “[Include any findings from imaging or laboratory tests if results are available.]”
Prior treatments: “[If the patient has had prior treatments, summarise their response and any changes since the last visit.]”
By adding phrases like “if applicable” or “if available” to your prompts, you give the AI the flexibility to skip unnecessary information, ensuring that only relevant data is included in the final note.
6. Encourage Specificity in Each Section
For the AI to generate meaningful clinical insights, your prompts should encourage specificity in each section of the note. Whether you’re using the SOAP format or another structure, ensure the AI is directed to provide detailed information in key areas.
Subjective: Be specific about what patient-reported symptoms, history, or goals need to be summarised.
Objective: Direct the AI to include measurable data, test results, or observations during the physical exam.
Assessment: Ask for a thorough evaluation based on the subjective and objective findings, including the practitioner’s professional opinions and measurable progress.
Plan: Ensure the AI generates clear recommendations for treatment, including session frequency, necessary equipment, patient education, and follow-up steps.
By crafting detailed prompts for each section, you ensure the AI provides comprehensive and accurate content that reflects the practitioner’s full evaluation.
Example: “[Summarise the therapist’s professional assessment, including measurable progress or concerns based on the patient’s report and physical exam.]”
Example: “[Provide detailed treatment recommendations, including session frequency, equipment requirements, and any necessary patient education.]”
By following these prompting tips, you can create highly effective clinical note templates that guide the AI to generate precise, relevant, and well-structured content, ensuring better outcomes and comprehensive patient records.
Using AI Tools to Help Create Your Templates
To assist with creating precise prompts, you can use freely available AI tools such as ChatGPT or Claude to help create your AI clinical note template. These tools can help you develop prompt templates by offering suggestions and refining your ideas to ensure the instructions are clear and specific.
How to use an AI tool for Prompt Creation:
Provide the AI tool (ChatGPT or Claude) an instruction to create an AI clinical note template as per the example below. Simply type or copy/paste instructions in the AI tool prompt such as the example below:
I want to create an AI prompt template that transforms a practitioner’s transcription into a structured clinical note, using only the information provided in the transcription without adding any extra content. The template should organise the note into four sections: Subjective, Objective, Assessment, and Plan. If a section has no relevant information in the transcription, leave it blank in the output. Each section should be summarised with concise information, using common medical abbreviations to ensure clarity and brevity.
Please use Australian English for spelling and terminology in the output.
The instructions for each section are as follows:
Subjective: [If information is provided, summarise the patient’s reported symptoms, concerns, and relevant medical history based on the transcription. Focus on key complaints, duration, and context provided by the patient. If there is no information for this section, leave it blank.]
Objective: [If information is provided, summarise objective findings, including physical examination results, vital signs, or other observations from the transcription. Use abbreviations for commonly used terms, such as "BP" for blood pressure or "HR" for heart rate, to keep the information concise. If there is no information for this section, leave it blank.]
Assessment: [If information is provided, summarise the practitioner’s assessment or diagnosis based on the subjective and objective information in the transcription. Ensure the summary includes all critical insights in a concise format. If there is no information for this section, leave it blank.]
Plan: [If information is provided, summarise the recommended treatment plan, listing therapies, medications, lifestyle advice, and follow-up actions as outlined in the transcription. Format as bulleted steps where appropriate for ease of reading. If there is no information for this section, leave it blank.]
Please create the template based on these guidelines, ensuring that each section follows the outlined structure, only includes information from the transcription, leaves sections blank if they lack information, and uses Australian English and abbreviations wherever possible.
The AI tool will then output an AI clinical note template that can be used in PracSuite. Here is an example of the output from the instructions given above:
[Create a structured clinical note using only the information provided in the transcription below. Organise the output into the sections Subjective, Objective, Assessment, and Plan. If a section has no relevant information in the transcription, leave it blank in the output. Each section should be summarised concisely, using common medical abbreviations to ensure clarity and brevity. Use Australian English for spelling and terminology throughout.]
Subjective:
[If information is provided, summarise the patient’s reported symptoms, concerns, and relevant medical history as conveyed in the transcription. Focus on key complaints, duration, and context provided by the patient. If there is no information for this section, leave it blank.]
Objective:
[If information is provided, summarise objective findings, including physical examination results, vital signs, or other observations noted in the transcription. Use commonly accepted abbreviations, such as "BP" for blood pressure and "HR" for heart rate, to maintain conciseness. If there is no information for this section, leave it blank.]
Assessment:
[If information is provided, summarise the practitioner’s assessment or diagnosis, based on the subjective and objective information in the transcription. Ensure the summary is concise, including all critical insights. If there is no information for this section, leave it blank.]
Plan:
[If information is provided, summarise the recommended treatment plan, including therapies, medications, lifestyle advice, and any follow-up actions as outlined in the transcription. Use bullet points for ease of reading where appropriate. If there is no information for this section, leave it blank.]
The AI clinical note template can be further refined by providing additional instructions to the AI tool. These are the instructions entered into the AI tool after generating the template above to add a separate history section at the top of the clinical note.
Please refine the AI prompt template by adding a History section at the top of the clinical note template. This section should summarise any relevant past medical history, previous treatments, or other contextual details provided in the transcription.
The AI tool will then regenerate output. Here is an example of the AI clinical note template output that can now be used in PracSuite from the instructions given above:
[Create a structured clinical note using only the information provided in the transcription below. Organise the output into the sections History, Subjective, Objective, Assessment, and Plan. If a section has no relevant information in the transcription, leave it blank in the output. Each section should be summarised concisely, using common medical abbreviations to ensure clarity and brevity. Use Australian English for spelling and terminology throughout.]
History:
[If information is provided, summarise any relevant past medical history, previous treatments, or contextual details as conveyed in the transcription. If there is no information for this section, leave it blank.]
Subjective:
[If information is provided, summarise the patient’s reported symptoms, concerns, and relevant medical history related to the current visit. Focus on key complaints, duration, and context provided by the patient. If there is no information for this section, leave it blank.]
Objective:
[If information is provided, summarise objective findings, including physical examination results, vital signs, or other observations noted in the transcription. Use abbreviations for commonly used terms, such as "BP" for blood pressure and "HR" for heart rate, to maintain conciseness. If there is no information for this section, leave it blank.]
Assessment:
[If information is provided, summarise the practitioner’s assessment or diagnosis based on the subjective and objective information in the transcription. Ensure the summary is concise, including all critical insights. If there is no information for this section, leave it blank.]
Plan:
[If information is provided, summarise the recommended treatment plan, including therapies, medications, lifestyle advice, and any follow-up actions as outlined in the transcription. Use bullet points for ease of reading where appropriate. If there is no information for this section, leave it blank.]
Testing Your Template
After completing your template, you can test it with a sample dictation or conversation transcript by copying text into the Sample Transcript section.
Template Examples
SOAP Example
SOAP Example
Subjective:
- [Detailed narrative of the patient's self-report of their current status, symptoms, reason for visit etc (if available)]
- [Patient's activity level, disability, social history (mention only if applicable and available)]
- [Goals and prior response to treatment intervention (mention only if applicable and available)]
- [Information from family or caregivers (mention only if applicable and available)]
Objective:
- [Physical examination details (if applicable and available)]
- [Observations, tests, and measurements by the therapist (if applicable and available)]
- [Specific measurements and assessment findings (if applicable and available)]
Assessment:
- [Therapist's professional opinion based on subjective and objective findings (if applicable and available)]
- [Prioritised problems list (mention only if applicable and available)]
- [Progress towards stated goals (if applicable)]
- [Factors affecting progress and any need for modification in the plan (if applicable)]
Plan:
- [Detailed treatment plan including interventions, frequency, and duration (if available)]
- [Anticipated goals and expected outcomes (mention only if applicable and available)]
- [Equipment required and its usage (mention only if applicable and available)]
- [Education strategies for the patient (mention only if applicable and available)]
- [Referrals to other professionals (mention only if applicable and available)]