How to generate clinical documents after a scribe session

After every encounter, Medulla can generate seven (7) clinical documents to support your workflow. These include notes, transcripts, patient handouts, referral letters, consultation letters, sick notes, and care conferences.

Here's how it works and what to expect from each document:

1. Your Note and Transcript are auto-generated after every scribe session, provided there was a live transcript.

2. For the Patient Handout and Referral Letter, these can be auto-generated if you check the relevant box before starting your session, or you can choose to generate them manually afterwards.

   

3. For the Consultation Letter, Sick Note and Care Conference, you can generate them by clicking Generate within the relevant document tab after your session ends.

   

4. All documents, except the Transcript, can be edited and regenerated as needed. Each document also includes copy and print icons for quick sharing.

   

What to Expect in Each Document

1. Note
   This is a structured clinical summary of your scribe session transcript, including the patient's symptoms, exam findings, assessment and plan. The format depends on your selected encounter template (e.g., SOAP). You can also copy the note directly to your EMR encounter note by clicking the Copy to encounter note button.

2. Transcript
   This shows a word-for-word record of the conversation between you and your patient.

   

3. Patient Handout
   This is written for the patient to easily understand what was discussed during the encounter, the care plan, home-care advice, warning signs, and follow-up, where applicable.

   

4. Referral Letter
   This is a formal letter to a specialist, including the reason for referral, clinical summary, investigations/treatment provided, and relevant patient history.

5. Consultation Letter
   This is a formal reply to the referring provider, summarizing the assessment, differential diagnosis, investigations/treatment, and follow-up advice. This is applicable in a situation where the physician who conducted the encounter session is a Consultant.

   

6. Sick Note
   This note certifies that the patient was assessed and unable to attend work or school, including the recommended duration off and return conditions.

   

7. Care Conference
   This is a summary of a team meeting about a patient's care, including attendees, discussion points, action items and follow-up plan.