Enhancing Accuracy with Empathia AI

Using Empathia AI can significantly enhance your clinical documentation—but if you're new to AI, it's easy to overlook key steps that help the system capture relevant details and adapt to your unique style. This guide outlines best practices to improve the accuracy, completeness, and customization of your AI-generated notes.

1. Ensure Accuracy from the Get go

Achieving accurate notes starts with the right setup and habits:

i. Optimize the Audio Setup

• Make sure to grant permission to the microphone before recording to capture your conversation

• For virtual/ telehealth visits use a different recording type “Record Televisit”. This will ensure to capture audio from both your speaker & your microphone.

ii. Speak Clearly and Effectively

• Speak as you normally would with your patient. It is recommended to stick to one language throughout the consultation for improved accuracy.
• If you need to attend a phone call, walk out of the room or take a break for any reason, simply pause the recording.

iii. Set Up for Success

• Review your Note Settings to tailor note structure, terminology, and output to suit your documentation style.
• Activate settings like differential diagnosis or default consult letter, to reduce repetitive tasks

2. Create Comprehensive Notes

Use the following techniques to capture the full context of patient visits:

i. Use the right tools

• The Notepad & Past Medical Records feature allows you to type, copy/paste or dictate key patient information, past history or any observations that you make before or during the patient visit. Any information included here will be summarized as part of the final note

• The Smart Summary feature allows you to upload any patient reports like labs, test results or discharge summaries, to be easily summarized into the final note. Read details about the feature here. 

ii. Be Explicit and Structured

• State Physical Exam Findings Aloud: For example while auscultating the lungs, say “lungs clear bilaterally, no wheezing noted”
• Use Clear Transitions: If multiple people are present in the conversation, ensure to address them by name & their role at the start of the conversation. Summarize what each person states when transitioning within a conversation.
• If reviewing any paper reports during the encounter, state the summary out loud if relevant to the encounter.

3. Handling Multiple Problems in One Visit

Empathia AI can handle multi-issue visits with ease—just ensure clarity:

• Guide the Conversation: Redirect patients to discuss one concern at a time when possible & state when moving to the next medical issue. For example “Let’s now move on to your diabetes management
• Recap the plan at the end of visit for each problem addressed during the visit. For example “To recap, for your hypertension, we have changed your prescription & for your diabetes, we are scheduling some labs”

4. Enhancing the Assessment & Plan Section

Use documentation keywords or phrases to improve the note quality. For example -

• “The different possibilities…” → signals differential diagnosis
• “The plan is…” → starts the management section
• Use terms like “stable” or “unstable” for clinical clarity.

5. Using Templates

Your documentation should work for you—not the other way around. Our Template feature is built to be customizable and supports a wide range of note types - SOAP, consult letters, progress notes & even auxiliary notes like sick notes. Read more about how to create your own templates here.

With the right habits and tools in place, Empathia AI becomes more than just a note-taker—it becomes a powerful partner in delivering accurate and efficient clinical documentation. If you need further assistance, simply reach out to us at support@empathia.ai