Patient Record and AI Note-Taking Workflow

Overview

A staff training and workflow discussion on navigating patient records, documenting consultations, using AI-assisted notes, charting prosthetics, and handling consent and charges. Several processes are still being tested and require clarification.

Participants & Roles

• Clinical staff: Demonstrated patient-record navigation, consultation documentation, charting, and AI note-taking.
• Administrative/front-desk staff: Expected to support patient intake, paperwork, charting, and billing workflows.
• Hannah: Identified as a contact for developing and sharing note templates.

Decisions Made

• Staff may use either the dashboard or calendar to open a patient record; the dashboard is preferred by some because it is cleaner, but both show the same patient screen.
• Patient-facing conversations should be documented when they capture important treatment recommendations, risks, costs, and informed-consent discussions.
• AI-generated notes must be reviewed and corrected before being added to the patient record. Explicitly identifying prosthesis type—for example, partial versus complete—is important for accuracy.
• A shared consultation template should be developed, with a separate template considered for immediate cases.
• Recording should not begin without informing the patient until appropriate consent and signage are in place. Staff suggested describing it as a digital note-taking system rather than emphasizing AI.
• The exact division of clinical and front-office responsibilities for tooth charting and charges remains unresolved.

Action Items

• Develop and share a standard consultation-note template; consider a separate template for immediate cases.
• Finalize the iPad intake and consent process, including notice that digital recording may be used.
• Clarify when clinical staff should enter tooth charting and charges versus handing those tasks to front-office staff.
• Continue testing AI note accuracy, recording limits, and how to retain or extend recordings for longer consultations.

Discussion Points

Patient navigation and documentation

• Opening a patient from the calendar or dashboard displays the patient record. Completed appointments disappear from the dashboard, while the calendar remains unchanged.
• Previous EPA treatment is available in the patient history or clinical sidebar.
• Administrative notes may contain information that should not be visible to patients; staff discussed hiding sensitive notes where appropriate.
• To document a consultation, search for the consultation entry and open the appropriate new- or existing-patient option so it links to the day’s appointment.
• A clinical note can be entered by selecting the relevant treatment and tooth, then typing or dictating the note.

AI-assisted consultation notes

• A structured template can guide the AI to place information under headings such as Present prosthesis, Complaints, Examination, Quotes given, and Treatment plan, rather than generating an unstructured narrative.
• The recording device is activated by holding its button, then recording can be paused and a summary generated. The transcript or summary can be copied into the patient note.
• A test suggested that the AI may misclassify a prosthesis if the clinician does not clearly state whether it is partial or complete.
• Recording may be limited to about five minutes; staff discussed pausing, generating a summary, and continuing if necessary. The process for retaining earlier recordings needs further testing.
• Important documentation includes advice about treatment risks, the reasons for recommendations, likely outcomes based on the patient’s history, and financial or insurance conditions.

Consent and patient communication

• Planned changes include iPads at reception for paperwork and consent before the patient enters the treatment area, along with front-desk photography for identification.
• The consent process will need to address recording and ensure patients receive a treatment plan. Staff also discussed retaining a signed record that the plan, including its cost, was provided.
• Until consent language and signage are in place, patients should be told that a digital note-taking system may be used.

Charting and charges

• For a partial denture, the workflow discussed was to update the base chart first: mark missing teeth, select the relevant appliance, and associate it with the appropriate spaces.
• Charges can then be added and adjusted in the charting system, but staff were uncertain whether this should happen during the clinical appointment or afterward.
• One proposed approach is for clinicians to record the consultation and treatment plan, then allow front-office staff to complete charting and billing while clinical care continues.