Tone
Instructions that set the style and “sound” of your note — how concise or detailed it is, the perspective (active voice), and how findings are summarized.
Be concise.
Be detailed.
Be verbose.
Summarize findings.
Write in the active voice.
Do not use pronouns.
Format
Instructions on how information is arranged and presented, covering layout (bullets, paragraphs) and emphasis.
Bold Abnormals
Write abnormals in all capitals.
Write in paragraph form
Write in point form OR write in point form (use dashes)
Maintain formatting.
Only list the objectives mentioned.
List only abnormal objectives.
Bring abnormal findings to the top of the objective category.
Dictation
Instructions governing the specific words or terminology to use, such as level of technicality, abbreviations, phrasing and even specified measurement units.
Use the following Legend:
Nrm = normal
Abn = abnormal
N/A = not applicable
N/E = not examined
Occ = occasional
Write in medical terminology.
Write in layman's terms.
Use (f/c) units of measurement.
Use veterinary abbreviations.
Sprinkle some magic 🪄
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Write follow-up recommendations based on the appointment.
Write differentials based on the appointment.
Create a detailed plan based on the information provided.
Create a discharge summary with these headings*:
What to Do
What to Watch For
When to Follow-Up
*Scribenote recommends that you review these outputs before including them in a saved record.
Content and Organization
Guidelines on what to include or exclude based on specifics of each appointment in your note, how to categorize findings, and how to reflect treatments or recommendations.
Include if the owner has declined treatments.
If the patient is vomiting, list the following differentials: Pancreatitis, Foreign body and gastroenteritis.
Include masses in the body system they are found in.
Include masses under the skin/integument category.
Include Anal gland expression under rectal/under other/at the end of the objective section.
Include all potential courses of treatments discussed with costs, even if declined (note if declined).
If vaccines noted, note locations: e.g. Rabies RH SQ 3y, DHPP/Lepto LH SQ 3y/1y, Lepto LH SQ 1y (if alone), Bord orally.
No diagnosis in Subjective.
Do not write subjective information in objective.
Only include exam findings in objectives (no assumption of condition).
Do not assume any follow-ups unless explicitly stated in the transcript.
Do not list recommendations unless discussed in the appointment.
Only use info in the transcript.
If there are no findings, return “not mentioned”.
Do not repeat information.