A great clinical note isn't just about capturing words; it’s about capturing the right clinical intent. Follow this guide to transform your documentation process from standard to specialized.
Step 1: Navigating to the Template Studio
To begin building or refining your templates, look at the left-hand sidebar of your InsightHealth dashboard.
Click on Template Studio.
From the Select note template dropdown at the top, you can either select an existing template (like the standard SOAP note) to modify, or use the Create a copy button to build a new version without losing the original.
Step 2: Defining Your Note Structure
The "Sections" area is the heart of your template. While a standard SOAP note includes Subjective, Objective, Assessment, and Plan, specialty-specific care often requires more nuance.
Customizing Sections: You can rename or rearrange sections to fit your specialty.
Specialty Terminology: In the Description field of each section, provide Aura AI with "hints." Mention specific types of data you want captured to "prime" the AI to look for specific clinical data.
Examples of Specialty-Specific Customizations:
1. Behavioral Health / Psychiatry
Focus: Mental status, risk assessment, and therapeutic modality.
Subjective: "Focus on the patient’s narrative regarding mood, sleep hygiene, and appetite. Capture specific stressors and any reported side effects from current psychotropic medications."
Objective (Mental Status Exam): "Document observations on appearance, speech patterns, affect, and thought process. Explicitly look for and state the presence or absence of suicidal/homicidal ideation (SI/HI)."
Assessment: "Synthesize the diagnosis based on DSM-5 criteria mentioned and note any changes in symptom severity scales."
2. Interventional Pain Management
Focus: Pain mapping, procedural history, and functional assessment.
Subjective: "Document the exact anatomical location, radiation (dermatomal pattern), and quality of pain (e.g., sharp, burning). Record the percentage of relief obtained from the most recent procedure and any changes in Activities of Daily Living (ADLs)."
Objective: "Focus on provocative maneuvers for pain generation, including Facet loading, Gaenslen’s test, and Straight Leg Raise (SLR). Capture localized tenderness over specific spinal levels and document current sensory/motor deficits."
Plan: "Outline the specific scheduled procedure, including the level, side, and approach. Include medication changes—specifically anticoagulation management—and any required pre-authorization steps."
3. Neurology
Focus: Neurological exam findings, cognitive assessment, and symptom localization.
Subjective: "Detail the onset, frequency, and duration of symptoms like tremors or paresthesia. Capture history regarding seizure activity (aura, postictal state) or migraine triggers."
Objective: "Document findings for Cranial Nerves II-XII, motor strength (0-5), and sensory testing. Explicitly capture results from cerebellar testing (finger-to-nose), gait analysis, and deep tendon reflexes (DTRs)."
Plan: "Outline neuroimaging orders (MRI/CT), EEG/EMG scheduling, and titration schedules for anticonvulsants. Note any referrals for Neuropsychology or Physical Therapy."
Step 3: Mastering Verbosity Settings
Aura AI allows you to control the "density" of your notes. Choosing the right verbosity ensures your notes are compliant but readable.
Setting | Best For... | What it Does |
Brief | Quick follow-ups or routine checks. | Distills the conversation down to essential clinical facts. |
Balanced | Standard primary care or internal medicine. | Captures the narrative while trimming conversational filler. |
Comprehensive | Initial consultations or complex cases. | Includes detailed history, nuanced symptoms, and exhaustive plans. |
Best Practices for High-Quality Notes
To ensure Aura AI delivers the best results within your custom template:
Be Explicit: Aura AI listens to the dialogue. If you want a specific detail in the "Assessment" section, state your clinical impression clearly during the exam.
Set a Default: Once you’ve perfected a template, click "Make this as a default template" under the selection box to save time on every future patient encounter.
Test and Iterate: Use the Template Exchange to see how other providers in your specialty are structuring their notes for inspiration.