Integrating AI With Custom Forms

[Accordion]Overview

ClinicTracker Clinical Scribe is an AI-powered documentation assistant embedded directly into the EHR that helps providers create clinical notes faster and more accurately. 

Built directly into ClinicTracker, the AI-powered Clinical Scribe helps providers document sessions quickly and accurately by automatically turning conversations and notes into structured clinical records. It aligns with payer, billing, and compliance requirements, reducing errors and missing information. Cutting down the time spent on manual documentation, it allows clinicians to focus more on their patients and less on paperwork.

Why do you need it?

• Real-time and post-session AI documentation captures and converts conversations into structured clinical notes without storing audio.

• Built-in templates ensure accuracy and compliance by keeping notes consistent with clinical and payer requirements.

[Accordion]Getting Started

Preliminary Steps for Using Clinical Scribe in ClinicTracker

[Q] Initial setup

[A] Contact support to enable Clinical Scribe for your clinic. 

[Q] Clinical Scribe Licenses

[A] Add the required number of licenses by going to Utilities > License Manager.

[Q] Enable Clinical Scribe for staff member

[A] Go to Staff Info > System Permissions > Clinical Scribe> Enable Clinical Scribe Access

[Accordion] Compatible with Clinical Scribe

[Q] Custom Form types

[A] The custom form types that can be enabled for Clinical Scribe are: 

• Patient
• Staff
• Stand-Alone
• Progress Note

[Q] Form Field Types

[A] Form fields that can be enabled for Clinical Scribe are: 

• Textbox
• Memo With Format
• Memo Without Format
• Dropdown
• List Box
• List Box With Table
• Date Picker
• Time Picker
• Repeating List
• Grid View
• Checkbox
• Plan Goal Objective (i.e., Tx Planning Blocks)

[Accordion] Enabling Forms for Clinical Scribe

To use Clinical Scribe on your forms, you need to give the AI instructions about what information to look for and how to fill in each form field. These instructions help the system understand what data to capture from clinical notes or conversations and where to place it in the form. 

You can give basic instructions or more detailed ones, depending on how specific you want the results to be.

[Q] Form Details screen

[A] General AI Prompts: Include general information for the AI to follow when populating the form.

For example, whether to use only documented facts, how to handle missing or unclear details, how to format dates or names, and whether to summarize or quote information. You can keep the instructions basic or make them more detailed, depending on how much control and accuracy you need.

[Q] Form Property 

[A] AI Prompts: Clinical Scribe is enabled for a form when at least one field contains text in its AI Prompt property. 

Adding an AI Prompt tells the system that AI should be used to read clinical input and help populate the form. Once enabled, Clinical Scribe will follow the instructions you provide in each field’s AI Prompt to extract relevant information and fill in the appropriate fields on the form.

A detailed prompt helps the AI capture accurate, complete information that supports insurance, compliance, and clinical documentation requirements.

Here is an example of a detailed prompt for a Clinical Dependency Assessment form field:

"Document the client’s current and past substance use, including all substances used (such as alcohol, cannabis, opioids, stimulants, hallucinogens, prescription medications, caffeine, and others). For each substance, include the frequency of use (for example, daily, weekly, monthly, or binge patterns), length of use (in months or years), age at first use, and any periods of abstinence.

Include any history of substance use treatment or participation in substance use programs, such as the name of the program, when the client attended, and the client’s perspective on how helpful it was.

If the client has no current or past substance use, clearly indicate that."

[Accordion] After Clinical Scribe is configured

You can expect the following once Clinical Scribe has been successfully configured:

• In Form Builder, all users will see the Clinical Scribe lightbulb icon next to any Custom Form that has Clinical Scribe enabled.

• In the Form Listings view, all users will see the Clinical Scribe lightbulb icon to the left of any Custom Form that has Clinical Scribe enabled.

• If the user has Clinical Scribe enabled, they will see the Clinical Scribe lightbulb button in the lower-right corner when they open a Custom Form.

  

• When the Clinical Scribe widget is opened, all fields enabled for Clinical Scribe will be highlighted with a border.

[Accordion] Clinical Scribe Widget

You can use the Clinical Scribe Widget for the following:

• Record live sessions with multiple participants: Capture audio from all speakers in real time, distinguishing between voices when possible to create an accurate transcript.

• Record dictations with a single speaker: Focus on one speaker to ensure precise capture of spoken content for documentation purposes.

• Type transcript text: Manually enter text directly into the system, allowing the user to add notes or corrections in real time.

• Upload audio or video files: Provide existing recordings for AI transcription, enabling flexible use of pre-recorded sessions or dictations.

• Automatically generate output and populate Custom Form fields: The AI processes the audio or typed input and fills in the corresponding form fields according to the instructions provided.

• Regenerate the output transcription: Re-run the AI transcription process to update the form with revised or corrected content as needed.

• Speak or type to edit the output: Make real-time corrections or additions by either speaking directly to the system or typing edits, ensuring the final content is accurate and complete.

• Recover a previously interrupted session: Restore an active session if it was disconnected or paused, as long as the user did not manually end it, preventing loss of ongoing work.

Clinical Scribe webinar: https://www.youtube.com/watch?v=3kUgwkKJEfM

[Accordion] Support