Clinical Documentation with AI

The Documentation Burden

In the previous lesson, we explored patient communication and health literacy. Now let’s build on that foundation. A hospitalist sees 15-20 patients per day. Each patient encounter requires an assessment note, potentially a progress note, orders documentation, and coordination notes. That’s easily 2-3 hours of pure documentation work per shift.

Multiply that across a career, and clinicians spend years of their professional lives typing. AI can cut that documentation time significantly – not by replacing your clinical thinking, but by handling the structural and narrative heavy-lifting.

What You’ll Learn

By the end of this lesson, you’ll know how to use AI to create documentation templates for your most common encounter types, draft narrative sections efficiently, and structure clinical summaries – all while maintaining compliance and accuracy.

From Clinical Thinking to Clinical Writing

Here’s something you already know but might not have articulated: the hardest part of documentation isn’t the clinical thinking. It’s translating your clinical thinking into properly formatted, complete, compliant text.

You’ve already assessed the patient. You know what’s going on. You know the plan. The bottleneck is typing it all out in the right format with the right language.

That’s exactly what AI does well – it takes your clinical thinking (in rough form) and produces structured, well-written documentation.

The Template-First Approach

The most efficient way to use AI for documentation isn’t generating notes from scratch each time. It’s building templates for your common scenarios, then customizing them.

Step 1: Identify your high-volume note types

What do you document most often? For most clinicians, it’s 5-10 encounter types that make up 80% of their notes.

Examples:

• Routine follow-up visits for chronic conditions
• Post-operative assessments
• Admission histories and physicals
• Discharge summaries
• Nursing shift assessments
• Therapy progress notes

Step 2: Create a template for each

AI: "Create a clinical documentation template for a
[type of encounter] in [your setting].

Format requirements:
- Follow [SOAP / DAP / narrative] format
- Include sections for: [list your required sections]
- Use professional clinical language
- Leave [BRACKETS] for patient-specific information

The template should cover a typical [encounter type]
including common findings, standard assessments, and
routine plan elements.

Example of the style I need:
[Paste a sample note if you have one, de-identified]"

Step 3: Build a library

Save your templates somewhere accessible. Each time you need to document, pull the relevant template and customize rather than starting from a blank screen.

Quick Check

How many distinct encounter types do you document regularly? Write down the top five. Those are your first five templates.

SOAP Note Generation

SOAP notes are universal. Here’s how to use AI to draft them efficiently:

AI: "Create a SOAP note template for a [specialty] provider
seeing a patient for [chief complaint/visit type].

Subjective: Include common history elements for this
presentation, with blanks for specifics.

Objective: Include standard exam findings with normal
baseline values and blanks for actual findings.

Assessment: Include a framework for clinical reasoning
with differential considerations.

Plan: Include common interventions, follow-up
recommendations, and patient education points.

Mark all patient-specific fields with [BRACKETS].
Use standard medical abbreviations appropriate for
[your specialty]."

Example output for a diabetic follow-up:

SUBJECTIVE:
[Patient name] presents for routine diabetes follow-up.
Reports [good/fair/poor] compliance with medication regimen.
Current medications include [list]. Denies/reports [symptoms:
polyuria, polydipsia, blurred vision, numbness/tingling in
extremities]. Last meal [time]. Home glucose readings
averaging [range] over past [timeframe].
Diet: [adherence level]. Exercise: [frequency/type].

OBJECTIVE:
Vitals: BP [value], HR [value], Wt [value] ([change from last])
General: [appearance]
Extremities: Pedal pulses [palpable/diminished], sensation
[intact/diminished] to monofilament testing bilaterally
Skin: [foot exam findings]

Labs:
- HbA1c: [value] (previous: [value], date: [date])
- Fasting glucose: [value]
- Lipid panel: [values]
- Renal function: Cr [value], eGFR [value]

ASSESSMENT:
Type 2 Diabetes Mellitus - [controlled/uncontrolled]
HbA1c [at/above/below] goal of [target]
[Additional diagnoses]

PLAN:
1. [Continue/Adjust] [medication] [dose change if applicable]
2. [Additional medication changes]
3. Lifestyle: [dietary counseling/exercise recommendations]
4. Referrals: [ophthalmology/podiatry/diabetes education] due [date]
5. Labs: Repeat HbA1c in [timeframe]
6. Follow-up: [timeframe]
7. Patient education provided regarding [topics]

This template takes 30 seconds to customize versus 10 minutes to write from scratch.

Discharge Summary Drafting

Discharge summaries are notoriously time-consuming. AI helps structure them:

AI: "Create a discharge summary template for a patient
being discharged from [unit type] after [type of stay].

Include these sections:
- Admission diagnosis and date
- Hospital course summary
- Procedures performed
- Discharge diagnosis
- Condition at discharge
- Discharge medications (with changes from admission highlighted)
- Follow-up appointments and instructions
- Activity restrictions
- Diet modifications
- Warning signs requiring return to ED
- Patient/family education provided

Use clear headings. Keep language professional but readable.
Mark all patient-specific fields with [BRACKETS]."

Pro tip: When you have the clinical details ready, you can use AI to transform your rough notes into a polished summary:

AI: "Transform these rough notes into a formatted discharge
summary following the template above:

[Your rough notes, DE-IDENTIFIED:
- 3 day stay for pneumonia
- IV antibiotics x 48hr then switched to oral
- Chest X-ray showed improvement
- O2 weaned to room air
- Going home on augmentin 10 days
- Follow up with PCP 1 week
- Return if fever, worsening SOB, chest pain]"

AI will structure this into a professional, complete discharge summary that you review and sign.

Progress Notes and Handoff Summaries

Shift handoff is another documentation pain point. AI can help you structure concise, complete handoff summaries:

AI: "Create a nursing handoff summary template using the
I-SBAR format (Introduction, Situation, Background,
Assessment, Recommendation) for a [unit type] patient.

Include:
- Patient identifiers section [BRACKETS]
- Current situation (why they're here, current status)
- Relevant background (pertinent history, allergies)
- Assessment (current vitals trend, key findings, concerns)
- Recommendations (tasks for next shift, pending items)
- Safety alerts (fall risk, isolation, special precautions)

Keep it concise -- this needs to be communicated verbally
in under 3 minutes per patient."

Handling Specialty-Specific Documentation

Different specialties have different documentation patterns. Tell AI about yours:

AI: "I'm a [specialty] provider. Our documentation requires:
- [Specific format: e.g., BIRADS for radiology, functional
  assessments for PT/OT, behavioral observations for psych]
- [Required elements: e.g., cognitive status for geriatrics,
  wound measurements for wound care]
- [Regulatory requirements: e.g., therapy minute tracking,
  restraint documentation]

Create a template for a [common encounter in your specialty]
that includes all required elements."

Quick Check

Does your specialty use a standardized assessment tool or scoring system? If so, AI can create a documentation template that incorporates the scoring criteria and interprets common results.

The Review Workflow

Here’s your documentation workflow using AI:

1. See the patient – focus on the clinical encounter, take brief notes
2. Select your template – pull the appropriate one for this encounter type
3. Customize with AI (if needed) – feed rough notes to AI for formatting
4. Review carefully – check every clinical detail against your assessment
5. Edit and sign – make corrections, add nuance, finalize in EHR

Common review catches:

• AI may default to “normal” findings you didn’t specify – change to actual findings
• AI may include plan elements that don’t apply – remove them
• AI may use slightly different terminology than your facility prefers – standardize
• AI may miss nuances of your specific patient’s presentation – add them

The review step is non-negotiable. But reviewing and editing a structured draft is always faster than writing from scratch.

Time Tracking: Measuring Your Savings

Keep a simple log for your first two weeks:

Most clinicians report 40-60% time reduction on narrative documentation once they’ve built their template library and refined their workflow. That’s 1-2 hours per shift returned to patient care.

Exercise: Build Your First Template

Choose your most common encounter type. Use the prompts in this lesson to generate a complete documentation template.

Then use it on your next three encounters of that type. After each use, note what you had to change. Refine the template based on those notes.

By the third use, you should have a template that needs minimal customization and saves significant time.

Key Takeaways

• Build templates for your 5-10 most common encounter types – this is your biggest time investment with the biggest payoff
• Use de-identified information and hypothetical scenarios to protect PHI
• AI handles structure and narrative; you provide clinical accuracy
• The review step is non-negotiable – always verify clinical details
• Start measuring your time savings to demonstrate value
• Specialty-specific documentation works with AI when you specify your requirements

Next lesson: Creating patient education materials that are clear, accurate, and actually get read.