Quick Start Guide: Best Practices for Each Section of your Note

Sidekick: 

Quick Start Guide: Best Practices for Each Section of your Note

Note Sections for Evaluations and Daily Notes

The automatic dictation modes can be used in the note sections outlined below. This guide will review best practices for which mode to use when. Please note, there are some nuances to how each dictation mode works within different note types (i.e. evaluations vs progress notes) which will be highlighted below.

Subjective
Use Auto-Note to record subjective conversations with patients.

• Best practice: start the Auto-Note when you first begin your patient encounter. When you have finished your subjective interview we recommend pausing Auto-Note to allow for suggestions to populate. If Auto-Note makes a suggestion, you can select and edit that specific suggestion. Once you are finished you can send that information to your note. 

  • Progress Visits and Discharge Notes: 

    • Use Auto-Note to capture subjective conversations with patients.The AI is unable to reference previous notes in a patient’s case at this time, so make sure to discuss the patient's progress since the last reporting period. When gathering your patient’s subjective history, verbalizing current functional limitations and progress in therapy is essential to capture more robust subjective suggestions.

    • Please note: Our AI cannot read historical notes for the entire episode of care at this time, so it cannot include a comparison of a past subjective patient report or status without audio from the patient during each session. 

• If you would like to add more detail to the subjective section of your note after the patient has left we suggest using the Smart Dictation mode to narrate any missing information.

Objective

Smart Dictation mode works best for recording objective measures into the free text Objective section of your note.

• Auto-Note may capture some objective measures but the accuracy of the objective measure capture is decreased compared to Smart Dictation.

• Please Note: Today, we do not populate suggestions from our Auto-Note or Smart Dictation modes into the structured fields of the Objective section of your EMR. We recommend using our Direct Dictation mode (control + shift + Y) to narrate into any text box including the text boxes within the structured Objective fields.
  
  

Interventions

Use Direct Dictation to add interventions into the text box sections of your note.

• The Direct Dictation feature that can input information directly into the EMR anywhere there is a text box. To access this, you will need to use the keyboard shortcut: “control + shift + Y”. This feature is designed to help you dictate anywhere inside your EMR that our automatic modes do not populate to. This can be very helpful for dictating information to the interventions section of your note.

• If you are using either WebPT SOAP2 or Raintree as your EMR, we do provide a Smart Interventions feature. You can find help guides on using that specific feature here for SOAP2 or here for Raintree.

• Please note: At this time, Sidekick does not automatically place interventions into your note (unless you are using SOAP2 or Raintree as mentioned above). If you record interventions with either Auto-Note or Smart Dictation running, Sidekick will take that information and use it for context for the Assessment or possibly add them to the Objective Measures section of your note.
  
  

Assessment

Use Auto-Note while you educate your patient about their condition and outline their need for skilled Physical Therapy. 

• The AI will generate suggestions for your assessment based on your patient education and what it has captured for your subjective section using Auto-Note. 

• You can also use our Smart Dictation mode to summarize and enter your Assessment into the EMR. Often, a successful Assessment comes from a combination of using both dictation modes and your own clinical judgment. 

  • Progress Visits and Discharge Notes: 

    • You can use Auto-Note to discuss the patient’s progress since the last reporting period when talking to the patient so this can be added into the Assessment section.

    • You can also use Smart Dictation to summarize and add to your Assessment as with the previous note types.

Goals    

Auto-Note will suggest Goals based on the content from the recording.

• As with the Assessment section, you can also leverage Smart Dictation mode to ensure you have the exact goals you want in the note.

Plan

Auto-Note will generate basic plan statements for you. 

• To further refine these, you can either review your plan with your patient while Auto-Note is recording, or use Smart Dictation after you are done with your patient to outline the plan.