As a general practitioner, managing multiple patient interactions efficiently is crucial for maintaining high-quality care. Proper clinical documentation is essential, especially when dealing with numerous patients in a day. This guide will walk you through creating detailed and organized split notes, ensuring you capture all necessary information with precision.

When documenting patient interactions, the goal is to present information clearly and concisely. Let's explore how to format a clinical note using a common template structure, such as the SOAP format (Subjective, Objective, Assessment, Plan), while focusing on split notes for multiple patients.

Summary Statement: Begin with a brief overview. For instance, "Two patients seen for routine check-ups. Both patients presented with minor complaints. No significant abnormalities found."

Patient 1: John Doe

• History: Record the patient's background and presenting symptoms. Example: "John Doe, a 45-year-old male, presented with a mild headache and fatigue for the past three days. He denies any recent illness or significant stressors. No history of migraines or chronic headaches."

• Examination: Detail the findings from the physical examination. For instance, "Vital signs are within normal limits. Neurological examination is unremarkable. No signs of distress or discomfort noted."

• Plan: Outline the management strategy. Example: "Advised to stay hydrated and rest. Over-the-counter paracetamol recommended for headache relief. Follow-up in one week if symptoms persist."

Patient 2: Jane Smith

• History: Include relevant medical history and current complaints. Example: "Jane Smith, a 30-year-old female, presented with a sore throat and mild cough for the past two days. She reports no fever or difficulty swallowing. No known allergies or recent travel history."

• Examination: Provide examination results. For instance, "Throat examination reveals mild erythema without exudate. Lungs are clear on auscultation. No lymphadenopathy noted."

• Plan: Describe the proposed treatment. Example: "Recommended saltwater gargles and increased fluid intake. Advised to use lozenges for throat discomfort. Follow-up in three days if symptoms worsen."

Incorporating AI medical scribes like Notis AI Medical Scribe can significantly enhance the documentation process. These virtual scribes automate the creation of medical notes, reducing the manual effort required and improving accuracy.

Time Efficiency: Notis can decrease documentation time by 80%, allowing practitioners to focus more on patient care. On average, users save 2 hours daily on administrative tasks.

Ease of Use: With direct integration through WhatsApp, Notis simplifies the workflow without requiring additional software. The familiar interface ensures a seamless transition.

High Accuracy: The AI-powered voice-to-text technology boasts a 99% accuracy rate, ensuring precise and reliable transcription of medical notes.

By leveraging AI technology, general practitioners can enhance patient documentation, streamline workflows, and ultimately improve patient care. Embracing tools like Notis AI Medical Scribe empowers healthcare providers to manage patient records more efficiently and effectively.