Correctly writing and formatting clinical documentation, especially for colorectal cancer consultations, is crucial for effective patient care and communication among healthcare providers. Utilizing a structured template ensures comprehensive and clear documentation. Below, we explore each section of the template with detailed examples to guide colorectal surgeons in mastering this documentation process.

Patient Introduction

This section introduces the patient, summarizing key personal and visit-related information. For instance:

"I had the pleasure of seeing John Doe on October 15, 2023. He is a 62-year-old male seen today with his wife."

Medical History

Detail the patient's medical history, including recent diagnoses and relevant past medical conditions. For example:

"He has been recently diagnosed with stage II colorectal cancer. The patient reports abdominal pain for three months. He denies weight loss. He reports occasional blood in stool. He has a 10-year history of hypertension, which may have worsened over the past year."

Family and Surgical History

Include relevant family history and previous surgeries:

"Family History: Father had colon cancer at age 70. Surgical/Medical History: Appendectomy in 2005."

Procedures and Tests

Document any procedures and test results:

"Colonoscopy (Dr. Thomas Kelly - September 20, 2023): Found a large polyp in the sigmoid colon. Biopsy (September 25, 2023): Confirmed adenocarcinoma. Blood Test (October 1, 2023): Elevated CEA levels."

Examination Findings

Summarize the physical examination findings:

"Clinical examination demonstrated tenderness in the lower abdomen. There was evidence of a palpable mass. Digital rectal examination was normal. He has mild anemia and slight weight loss. He has absence of jaundice."

Impression and Plan

Outline the clinical impression and future plan of care:

"I have ordered the following: MRI and PET scan to assess the extent of the disease, in case he requires chemotherapy. His case will be presented at the tumor board meeting. Although the mass is large, it appears localized. I am not sure he will need chemotherapy. He is a good surgical candidate."

In the specialty of colorectal surgery, precise and efficient documentation is paramount. AI medical scribes, such as Notis AI Medical Scribe, offer transformative solutions to streamline this process, allowing colorectal surgeons to focus more on patient care.

Efficiency and Time Savings

Notis significantly reduces documentation time by converting patient interactions into structured SOAP notes, saving healthcare providers up to two hours daily. This reduction in administrative tasks enables more focus on patient interactions and care.

Ease of Use and Integration

Notis integrates seamlessly with familiar platforms like WhatsApp, requiring no additional software or training. This ease of use ensures quick adoption and efficiency improvements without disrupting existing workflows.

Accuracy and Multilingual Support

With a 99% accuracy rate in transcribing medical notes and support for 56 languages, Notis ensures reliable documentation across diverse patient populations, enhancing communication and care quality.

Comprehensive Documentation

By generating structured SOAP notes and analyzing medical documents and images, Notis provides comprehensive documentation solutions, facilitating better patient charting and clinical note management.

In conclusion, leveraging AI medical scribes like Notis can revolutionize the documentation process for colorectal surgeons, improving accuracy, efficiency, and ultimately, patient care. Embracing such technology in patient documentation practices ensures that healthcare professionals can dedicate more time to their primary role—providing high-quality care to their patients.