PracSuite AI provides several standard AI clinical note templates that cover a range of common clinical note formats in Australia. These options are available to all PracSuite users:
SOAP - Subjective, Objective, Assessment, Plan
SOAPIE - Subjective, Objective, Assessment, Plan, Intervention, Evaluation
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 Notes templates, you can create custom AI clinical note templates to meet your individual needs or comply with your organisation's clinical notes policies.
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 as an AI prompt engineer. 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:
Step 1: Define the structure of your clinical note (e.g., SOAP format).
Step 2: Use the tool to brainstorm potential prompts for each section. For example, you can input: "Create a prompt for summarising the patient’s symptoms in the subjective section of a SOAP note."
Step 3: Refine the generated prompt by incorporating specific clinical language or instructions relevant to your practice.
Example of an AI tool Prompt Assistance:
Your input:
"I need a prompt that instructs the AI to summarise the patient’s symptoms, goals, and the reason for their visit."
The AI may generate:
"Summarise the patient's symptoms, their primary concerns, and goals for treatment, as reported by the patient during the consultation."
By using an AI tool in this way, you ensure that your clinical note templates are highly customised, efficient, and precise, saving time and improving the accuracy of documentation.
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)]