–How Generative AI Can Save Time and Enhance Care
Medical professionals are familiar with the phrase “time is of the essence,” especially when it comes to patient care. The demand for meticulous medical documentation has become an additional task that eats away at a limited time, affecting both patient care and our own well-being. A study published in the Annals of Internal Medicine found that clinicians spend nearly double the amount of time on electronic health records (EHRs), patient notes, and administrative tasks as they do on direct patient care. Medscape’s 2019 survey indicated that bureaucratic tasks are a leading cause of burnout among 44% of physicians. With statistics like these, it’s evident that the healthcare industry is ripe for change.
The Rise of Medical Scribes
Enter medical scribes. These trained professionals have lightened the administrative burden, improving clinician and patient satisfaction, according to a study in “JAMA Internal Medicine,” clinicians who employed scribes to manage patient notes saw improved care due to increased face-to-face interactions with patients. Research also found that clinicians who used scribes also reported higher job satisfaction and reduced feelings of burnout.
Generative AI: The Digital Scribe
However, scribes aren’t accessible to everyone, and that’s where generative AI comes into play. Thanks to advancements in technology, we now have the potential for an AI-powered medical scribe that fits right into our pockets. In my practice, by using specific prompts with generative AI platforms like ChatGPT, I can complete 80% of my charting as I walk back to my desk from interacting with a patient.
Creating Custom Prompts
Using the pre-made prompts I will provide, I’ve created a head start, allowing me, and soon you, to focus on refining and editing notes rather than starting from scratch. This streamlined approach not only makes the job faster but also more accurate. And because these prompts are customizable, they can easily be adapted to fit individual needs and workflows.
Sample HPI Prompt for Patient Intake
HPI Note TemplateHPI Note Template
“Organize the information I will give you in the following format:
Chief Complaint
- Description: Describe the main issue using terms a patient would use.
- Details: [insert details]
History of Present Illness (HPI)
- Narrative: Address the seven dimensions of a patient’s symptoms: location, quality, quantity, timing, setting, aggravating/relieving factors, and associated symptoms. Include pertinent positives and negatives.
- Details: [insert details]
Past Medical History
- Conditions & Treatments: List out previous medical conditions, treatments, and outcomes.
- Details: [insert details]
Past Surgical History
- Surgeries & Outcomes: Detail any surgeries the patient has had and the outcomes.
- Details: [insert details]
Family History
- Medical Background: Note any family history of diseases, conditions, or other relevant medical information.
- Details: [insert details]
Social History
- Lifestyle: Include details on tobacco use, drug use, and alcohol consumption.
- Details: [insert details]
HEADS Pediatric Assessment (Ages 10-20)
- Assessment Areas: Cover Home environment, Education and employment, Activities, Drugs, Sexuality, and Suicide/depression.
- Details: [insert details]
Review of Systems (ROS)
- Organ Systems: Document relevant organ systems, noting positive and negative findings.
- Details: [insert details]
Vital Signs
- 24-hour Range: Present vital signs in table format.
- Table: [insert table here]
Physical Examination
- Summary: Summarize the general examination as well as pathology-specific findings for the heart, lungs, abdomen, and other relevant organ systems.
- Details: [insert details]
Laboratory Results
- Test Data: List lab results in table format, including the date of each test.
- Table: [insert table here]
Imaging
- Type & Findings: Describe the type of imaging performed and note impressions of findings.
- Details: [insert details]
Assessment
- Diagnosis: Provide a narrative summarizing the diagnosis or differential diagnoses, as well as an interpretation of labs and imaging.
- Details: [insert details]
Clinical Plan
- Treatment Strategies: Itemize the proposed treatment or management strategies, including any recommended follow-ups.
- Itemized List: [insert itemized list]
Sample SOAP Prompt for Patient Update
“Organize the information I will give you in the following format:
Subjective
- Clinical Change: Has the patient experienced any changes in symptoms or overall condition since the last evaluation? If yes, describe.
- Appetite: Has the patient been eating adequately? Any changes in appetite?
- Sleep Quality: How well has the patient been sleeping? Any changes in sleep patterns?
- Pain: Is the patient experiencing any pain? If yes, describe location, character, severity, timing, context, modifying factors, and associated symptoms.
Objective
- Vital Signs:
- Blood Pressure:
- Pulse:
- Respiratory Rate:
- Temperature:
- Oxygen Saturation:
- Other:
- Focused Physical Exam: Note findings related to patient’s chief complaint and any other relevant systems.
- General Appearance:
- Heart:
- Lungs:
- Abdominal:
- Extremities:
- Other:
Assessment
- Status: Where is the patient holding (ICU, general ward, etc.)?
- Last 24 Hours: Summarize the assessments and interventions from the past 24 hours.
- Diagnosis: Based on the current findings, what is the diagnosis or differential diagnosis?
- Current Findings: Summarize the key objective findings that are guiding today’s clinical decision-making.
Plan
- Immediate Actions: What immediate interventions are necessary based on the current assessment?
- Treatment Plan: Medications, therapies, or procedures for the current diagnosis.
- Follow-up: Next steps, including diagnostic tests to be ordered, and when the patient should be re-evaluated.
Once you’ve fine-tuned a prompt that suits your practice, save it in a note-taking app or within the ChatGPT software for easy access. This simple workflow saves valuable time, allowing for more direct patient care and reducing the cognitive load that often accompanies the act of note-taking.
Navigating the Data Privacy Landscape
It’s crucial to mention the importance of data privacy and compliance with health information laws like HIPAA. Generative AI models are not currently HIPAA-compliant. However, you can use de-identified versions of a patient’s history, social history, or other clinically relevant information to maintain the essence of the clinical scenario without breaching confidentiality or privacy laws. While de-identified data is generally permissible under current rules, regulations can differ, and directions continually evolve. Therefore, consult legal and compliance experts, as the above information should not be considered legal or medical advice.
Final Thoughts
Ironically, generative AI may be able to bring the human touch back to medicine; by offloading the cognitive load of documentation where possible, we’re not only revolutionizing medical documentation but also taking a massive leap toward a healthcare system that emphasizes what truly matters—high-quality, patient-centered care. And in an industry where time is precious, that’s a game-changer.
