Clinical Documentation Assistant
PROHelp healthcare professionals write clinical notes, SOAP notes, discharge summaries, and care plans with proper medical terminology and compliance awareness.
Example Usage
I just finished seeing a 62-year-old male patient presenting with chest tightness and shortness of breath on exertion for the past 3 days. He has a history of hypertension and type 2 diabetes. Vitals are BP 158/92, HR 88, SpO2 96% on room air. ECG shows normal sinus rhythm. I need a comprehensive SOAP note for this encounter in general practice. Include ICD-10 code suggestions and a follow-up plan.
Skill Prompt
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How to Use This Skill
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Copy the skill using the button above
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Suggested Customization
| Description | Default | Your Value |
|---|---|---|
| The type of clinical document to generate (SOAP note, H&P, discharge summary, care plan, referral letter) | SOAP note | |
| The medical specialty context for the documentation | general practice | |
| Clinical details of the patient encounter | [describe encounter] | |
| Level of documentation detail (brief, standard, comprehensive) | comprehensive | |
| Compliance framework to follow for documentation standards | HIPAA-aware |
Important Notes
- Always de-identify patient information before using AI assistance – never include PHI in prompts
- AI-generated clinical documentation is a draft that requires thorough clinician review
- This tool does not constitute medical advice or replace clinical judgment
- Follow your facility’s specific policies regarding AI-assisted documentation
- Verify all medication names, dosages, and diagnostic codes before finalizing
Research Sources
This skill was built using research from these authoritative sources:
- Health AI CPD - ChatGPT for Healthcare Professionals Continuing professional development guide for using AI in clinical documentation and healthcare workflows
- BastionGPT Healthcare AI Prompts HIPAA-compliant prompt engineering strategies for healthcare documentation and clinical decision support
- PMC/NIH - Prompt Engineering in Healthcare AI Peer-reviewed research on effective prompt design for clinical documentation and medical AI applications
- Paubox - ChatGPT and HIPAA Compliance Analysis of HIPAA considerations when using AI language models in healthcare documentation
- HealthTech Magazine - Prompt Engineering for Healthcare Industry overview of how health systems are leveraging prompt engineering for clinical documentation efficiency
- AMA Guidelines on AI in Clinical Documentation American Medical Association guidance on responsible use of AI for clinical note generation