AI in the Exam Room: How to Document Faster Without Losing Accuracy
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Note bloat. Pajama time. Endless copy-paste. For many physicians, documentation is one of the biggest pain points in modern medicine. But AI is changing the game — and if used correctly, it can help you write better notes in less time, without compromising accuracy.
Why AI Documentation Tools Work
Generative AI tools excel at pattern recognition, formatting, and summarizing. When clinicians provide structured prompts, these tools can:
- Draft SOAP or H&P notes
- Summarize conversations for MyChart
- Auto-suggest ICD-10 codes
- Even prepare prior auth letters or consult summaries
During a recent webinar featuring Dr. Graham Walker, Dr. Matthew Sakumoto, and Dr. Kai Romero (Evidently’s Head of Clinical Success), we shared the essential prompting frameworks that every physician should know to save time and get the most out of AI tools.
This article provides some key tips for faster, smarter documentation and offers some specific examples so every physician can up their prompting game.
Tips for Faster, Smarter Documentation
1. Pre-Visit Summaries
Ask AI to summarize complex charts before the visit.
"Summarize this patient's past visits, labs, and imaging in under 200 words."
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