Medical notes made with Simplify v SOAP notes:
Simplify’s AI Medical Scribe builds on top of the traditional SOAP note format by providing a more comprehensive and detailed approach to documenting office and inpatient visits. Unlike the conventional SOAP note, which typically only include broad overview sections of Subjective, Objective, Assessment, and Plan sections, Simplify takes documentation to the next level by encompassing all facets of the patient encounter.
Simplify’s advanced AI technology is designed to streamline the documentation process for healthcare professionals, beginning with capturing the chief complaint, which sets the stage for the visit and guides the clinical assessment. Simplify then meticulously records the History of Present Illness (HPI), delving into the specifics of the patient’s current condition and symptoms, which is crucial for forming an accurate diagnosis.
In addition to the HPI, Simplify’s AI Medical Scribe documents the patient’s Past Medical History (PMH), providing a comprehensive overview of their previous health issues and treatments. This information is vital for understanding the patient’s overall health status and identifying any potential risk factors that may impact their current condition.
Simplify’s AI Medical Scribe also records the patient’s current medications and any known allergies, ensuring that the healthcare provider has a complete picture of the patient’s pharmacological history and any potential drug interactions or contraindications.
The Physical Exam section is another critical component of Simplify’s documentation. The AI scribe captures the findings of the physical examination in detail, providing insights into the patient’s physical health and any abnormalities detected during the exam.
Diagnostic Tests are also meticulously documented, including the results and interpretations of any laboratory tests, imaging studies, or other diagnostic procedures performed during the visit. This information is essential for confirming the diagnosis and guiding the treatment plan.
Finally, Simplify’s AI Medical Scribe concludes the documentation with a thorough Assessment and Plan section. This includes a summary of the diagnosis, the rationale behind the chosen treatment plan, and any follow-up instructions or recommendations for the patient (if you the practitioner want to include them.)
It’s important to note that while Simplify’s AI Medical Scribe significantly reduces the workload and stress associated with medical documentation, every generation produced by the system must be thoroughly reviewed by you, the practitioner, before using the generation in anyway. This ensures the completeness of the patient’s medical record, maintaining the highest standard of care. By incorporating Simplify into your practice, you can alleviate much of the documentation burden, allowing you to focus more on patient care and less on paperwork.
Legal Disclaimer: **We provide general information only, not billing, coding, or medical advice. We do not guarantee the accuracy of the suggested codes or material generated by Simplify or that the use of such codes or material will result in payment or reimbursement or that they will be accurate in anyway. The platform is not a substitute for billing and coding advice from qualified billers and codding experts.
