Avalon Health Clinic – AI Voice Dictation Module

Introduction

Welcome to the AI-Voice Dictation Module tutorial platform. This guide provides a step-by-step walkthrough of this module in the system, ensuring that users can efficiently navigate and utilize its features. Each section includes screenshots illustrating the actions being performed.

Overview

This module enables voice-powered transcriptions for medical records.

Step-by-Step Guide

1. Using Voice Dictation

Navigate to "Dictactions"by clicking Patients on the sidebar, You are going to see a list of the patients and their files. Select the Dictate button of the Patient you need to dictate for

Select the file you need to dictate e.g Clinical letter, Sick Note, Referral letter, Patient Encounter Summary, Patient Assessment, Prescription, Operation Note

Clinical letter.

• Click "Start Recording" to dictate
• Speak clearly into the microphone.
• Click "Stop" to save.

A Clinical Letter is a formal document used to communicate a patient's medical details between healthcare professionals. It typically includes:Diagnosis, Recommendation, Patient Email, Referral Email, Additional Email 1, referral selection, Additional Email 2, Letter Date, Letter Body

1. Diagnosis

This section outlines the medical condition or illness that the doctor has identified based on the patient’s symptoms, medical history, and test results. The diagnosis provides a clear understanding of the patient’s current health status and serves as the basis for treatment and further recommendations.

2. Recommendation

The doctor provides medical advice or suggested treatment options for the patient. This could include prescribed medications, therapy, lifestyle modifications, further diagnostic tests, or specialist referrals. The recommendation ensures that the patient and other healthcare providers understand the next steps in managing the condition.

3. Patient Email

The patient’s email address is included for communication purposes. It allows the clinic or specialist to send test results, appointment reminders, follow-up instructions, or additional medical information related to their diagnosis and treatment.

4. Referral Email

If the patient is being referred to another healthcare provider or specialist, the email address of the referral recipient is included. This ensures that the letter is directly sent to the appropriate professional for further medical assessment or treatment.

5. Additional Email 1

This field is used when there is a need to send a copy of the clinical letter to an alternative recipient, such as another doctor, a family member (with patient consent), or an administrative department for record-keeping.

6. Referral Selection

This section allows the doctor to choose the specific department or specialist the patient is being referred to. The selection ensures that the letter is directed to the right healthcare professional, such as a cardiologist, neurologist, physiotherapist, or any other required specialist.

7. Additional Email 2

Similar to Additional Email 1, this field is used to include another recipient who needs access to the letter. It ensures that all relevant parties involved in the patient’s care are informed, such as another medical consultant or an insurance provider.

8. Letter Date

The date the letter was created is recorded to keep track of when the diagnosis and recommendations were made. This helps in maintaining an accurate medical history and ensures timely action based on the doctor’s recommendations.

9. Letter Body

The main content of the letter, the Letter Body, contains a detailed summary of the patient’s condition, the findings from their consultation, diagnosis, treatment plan, and any recommendations. It is written in a structured format, ensuring clarity and professionalism. This section may also include a closing statement from the doctor, confirming the purpose of the letter and offering further assistance if needed.

Note: When using AI Voice Dictation, the doctor must explicitly mention each element to allow the AI to correctly analyze and process the content. For example, they should say:

• "The diagnosis is..."
• "The recommendation is..."
• "The referral email is..."

This helps the AI recognize key sections of the dictation and correctly structure the clinical letter. After completing the voice recording, a permission pop-up may appear, requesting approval to process and save the dictated content before generating the final letter.

Sick Note Dictation.

Referral Letter.

Patient Encounter Summary

The Patient Encounter Summary is a crucial module that allows doctors to record and document details about a patient’s visit. This feature ensures that every aspect of the patient’s condition, history, and treatment plan is captured systematically for future reference. Below is a breakdown of the key elements:

This section serves as the main interface where doctors can view and manage previous encounter notes. It includes options to go back, view all patient encounter notes, and record new summaries using AI-powered voice dictation.

Recording Options

Doctors can use Start Recording and Stop Recording buttons to dictate the encounter summary instead of manually typing. This enhances efficiency by allowing hands-free documentation, especially during consultations.

Name & Initial Note

• Name: The doctor assigns a name to the encounter note, which helps in easy identification and retrieval.
• Initial Note: This is an introductory section where the doctor can briefly summarize the encounter.

Patient Complaint

This field is used to record the primary reason for the patient’s visit. The doctor documents the symptoms and concerns expressed by the patient, which helps guide the diagnosis and treatment plan.

Patient History

The patient history section contains past health information relevant to the current consultation. This can include previous illnesses, chronic conditions, or recurring symptoms that may influence the diagnosis.

Medical History

This section focuses on the patient’s long-term medical conditions and past treatments. It includes any diagnosed diseases, previous surgeries, or long-term medication usage.

Drug History

Doctors document the patient’s previous and current medications, including prescription drugs, over-the-counter medicines, and herbal supplements. This helps prevent adverse drug interactions and guides safe prescribing.

Social History

This field captures the patient’s lifestyle habits and environmental factors that may impact their health. It may include smoking, alcohol consumption, occupation, or other social determinants of health.

Examination

The examination section details the physical assessment findings during the consultation. This includes vital signs, observed symptoms, and any abnormalities detected during the clinical examination.

Diagnosis

The diagnosis field is where the doctor records the medical condition identified based on the patient’s complaints, history, and examination findings. This guides the treatment and further investigations.

Treatment Plan

This section outlines the doctor’s recommended treatment approach for the patient. It may include prescribed medications, lifestyle changes, physiotherapy, or further medical procedures.

Investigations

Doctors document any additional tests or diagnostic procedures required, such as blood tests, X-rays, or MRIs. These investigations help confirm or rule out suspected conditions.

Date of Injury & Date of Surgery

These fields allow doctors to record specific dates for injuries or surgeries related to the patient’s condition. This ensures accurate medical records and helps with post-surgical follow-ups.

Date of Injury & Date of Surgery

Doctors can either type or use AI voice dictation to transcribe the encounter notes. Once completed, they can submit the note to finalize the documentation. This structured approach ensures that all essential medical information is accurately recorded, improving patient care, follow-ups, and coordination among healthcare professionals.

The Doctor can also veiw recorded Patient Encounter Summaries

Patient Assessments

The Patient Assessment module enables doctors to comprehensively document a patient's medical condition, symptoms, and history. This structured approach ensures that every aspect of the patient’s health is evaluated systematically. Below is a breakdown of the key elements of the assessment.

Patient Assessments Notes

This section allows doctors to navigate patient assessments, either by going back, viewing all previous assessments, or recording a new one using AI-powered voice dictation.

Recording Options

Doctors can use the Start Recording and Stop Recording buttons to dictate the assessment rather than manually typing, improving efficiency and accuracy.

Name & Initial Assessment

• Name (Optional) – The system can auto-generate a name if left blank.
• Initial Assessment – The doctor enters a brief title or name for the assessment to organize records efficiently.

Chief Complaints & Medical History

• Presenting Complaint – The primary reason for the patient’s visit, including symptoms experienced.
• History of Presenting Complaint – Details of previous occurrences of the complaint, including duration and frequency.
• Aggravating Factors - Factors that worsen the condition, such as physical activity or environmental conditions.
• Easing Factors – Any remedies or actions that alleviate symptoms, like rest or medication.
• Behaviour of Symptoms – The progression and pattern of symptoms, such as intermittent or continuous pain.
• Night Pain - Whether the patient experiences pain at night and how it affects their sleep.
• Medical History – The patient’s previous diagnoses, chronic conditions, and past treatments.

Chief Complaints & Medical History

The Red Flag section allows doctors to document any serious underlying conditions or warning signs, ensuring early detection of potentially life-threatening diseases. The fields include:

• General Health – Unexplained fatigue, weakness, or other significant health concerns.
• Weight Loss - Unexplained or rapid weight loss that could indicate a serious condition.
• Rheumatoid Arthritis – Symptoms such as joint pain, stiffness, or swelling.
• Drug Therapy – Issues related to medications, including adverse reactions or contraindications.
• Steroid Use – Previous or ongoing use of steroids that may impact the patient’s health.
• Radiographs – Information about any prior imaging tests such as X-rays or MRIs.
• Cord Symptoms – Signs of spinal cord compression, such as numbness or weakness.
• Cauda Equina Symptoms – Symptoms like urinary retention, fecal incontinence, or saddle anesthesia.
• Cervical Artery Dysfunction - Signs of vascular issues that could lead to serious conditions.
• Cervical Artery Dysfunction - Tuberculosis, Cancer, and Chronic Illnesses – Screening for conditions such as TB, cancer, cardiovascular diseases, respiratory disorders, epilepsy, thyroid dysfunction, diabetes, and osteoporosis.

Patient Expectations & Clinical Reasoning

• Patient Expectations – The patient’s expectations regarding diagnosis, treatment, and outcomes.
• Clinical Reasoning – The doctor’s interpretation of symptoms and diagnostic approach.

Physical Examination & Transcription

• Physical Examination - Detailed findings from a physical assessment of the patient.
• Transcription & Drawing Tools – Doctors can record the assessment using AI voice dictation or manually enter information. The system also includes a pain mapping tool, allowing doctors to mark areas of pain directly on a diagram.

Submission & Record Management

Doctors can save markings, enable drawing tools, and finalize the assessment by clicking Save Patient Assessment or Submit Patient Assessment.

This structured documentation process ensures accurate, efficient, and detailed patient assessments, improving diagnosis and treatment planning.

The Doctor can also veiw recorded Patient Assessments

Prescription Dictation

The Prescription Dictation module allows doctors to use AI-powered voice recognition to record, manage, and issue prescriptions for patients. This feature enhances efficiency, ensuring accurate and structured medication prescriptions while reducing manual data entry errors.

Doctors can navigate through the module using:

• Go Back – To return to the previous screen.
• Go To Patient File – To access the patient's full medical records.

Each prescription is linked to a specific patient, and their details are displayed at the top of the module, including:

• Name – e.g., Mr. Wisdom Balicholo
• Date of Birth (DOB) – e.g., 2004-06-06
• Gender – Male/Female/Other
• Email & Phone – Contact details for the patient.

Additionally, the organization's logo and address (e.g., Davidson Surgery, 31 N Broad Street, Middletown, Delaware, USA) are displayed to ensure professional documentation.

Voice Dictation Feature

Doctors can dictate prescriptions using AI-powered voice recognition. This function allows hands-free entry of medication details. The process includes

• Start Recording – Begins voice dictation for the prescription.
• Stop Recording – Ends the dictation and converts speech to text.

The system processes and structures the recorded details, ensuring the prescription follows proper medical documentation standards.

Prescription Validity & Repeats

Doctors can set prescription validity and repeat options:

• Valid Until – A specific expiration date can be set, after which the prescription will no longer be valid. If left blank, the prescription remains active indefinitely.
• Repeats Allowed – Determines the number of times the prescription can be refilled. A value of 0 means no refills are allowed.

Medication Items

Doctors can add and manage prescribed medications, ensuring each prescription includes all necessary details:

• Medication Name – The drug name (e.g., Amoxicillin, Ibuprofen).
• Dosage – The required dose (e.g., 10mg, 1 tablet).
• Quantity – The number of tablets, capsules, or doses prescribed.
• Instructions – Guidelines on how the patient should take the medication (e.g., "Take with food twice daily").
• Substitution Allowed – Indicates if an alternative brand or generic medication can be provided.
• Controlled Substance – Specifies if the medication is a controlled substance, requiring additional regulation.

Adding Medications

Doctors can add multiple medications per prescription. Each Medication Item follows the structure:

• Medication Name
• Dosage
• Quantity
• Instructions

Once all details are entered, doctors can add more medications or finalize the prescription.

Operational Note Dictation

The Operational Note Dictation module allows doctors to use AI-powered voice recognition to document surgical and procedural details efficiently. This feature ensures accurate, structured, and standardized documentation of medical procedures while reducing manual data entry.

Doctors can navigate through the module using:

• Go Back – To return to the previous screen.
• Go To Patient File – To access the patient's full medical records.

Each operational note is linked to a specific patient, with details displayed, including:

• Name – e.g., Mr. Wisdom Balicholo
• Date of Birth (DOB) – e.g., 2004-06-06
• Gender – Male/Female/Other
• Email & Phone – Contact details for the patient.

Voice Dictation Feature

Doctors can dictate procedural notes using AI-powered voice recognition for hands-free documentation. The process includes:

• Start Recording – Begins voice dictation for the operational note.
• Stop Recording – Ends the dictation and converts speech to text.

Procedure Details

Doctors must document various procedural details, including:

• Diagnosis – The primary condition being treated.
• Procedure – The surgical or medical procedure performed.
• Assistant – The medical assistant(s) involved.
• Anaesthetist – The professional responsible for anesthesia.
• Hospital – The location where the procedure was conducted.
• Referral Email – Contact email for referring physicians.
• Additional Emails – Additional referral contacts if needed.

Post-Operative Instructions

The system allows doctors to record post-operative care instructions, ensuring the patient and caregivers receive proper guidance. Instructions can include:

• Medication guidelines
• Follow-up appointment details
• Activity restrictions and rehabilitation protocols

Finalizing the Operational Note

Once all details are recorded and reviewed, doctors can submit the operational note for secure storage in the patient's medical records.

• Start Recording – Initiates voice recording.
• Stop Recording – Ends the voice input.
• Submit Letter – Saves and finalizes the operational note.