How to Use AI to Structure Consultation Notes

How to Use AI to Structure Consultation Notes

The AI consultation feature analyses voice recordings or typed notes and structures them into clinical documentation with SNOMED-coded problems, observations, and clinical sections.

How to Get There

In the Clinical Record step of a consultation, click the AI button.

Input Methods

• Voice - click the Voice button, speak naturally about the consultation, then click to stop. The recording is transcribed automatically
• Text - type or paste free-form consultation notes in natural language

What the AI Produces

The AI analyses your input and returns structured data:

• Problems with suggested SNOMED codes
• Clinical sections - History, Examination, Assessment, Plan
• Observations with values and units (e.g. BP 120/80 mmHg)
• Allergies with culprit and reaction information

Reviewing AI Output

Before anything is inserted into the consultation, you see a preview where you can:

• Select SNOMED codes - if the AI suggests multiple possible codes for a problem, choose the most appropriate one
• Include or exclude problems - deselect any problems that are not relevant
• Edit observation values - adjust any values the AI extracted
• Review clinical text - check and modify the structured notes before insertion

Click Confirm to insert the reviewed data into the draft consultation.

Audit Trail

Content generated by AI is marked in the consultation record for audit purposes. This ensures clinical governance can distinguish between clinician-authored and AI-assisted documentation.

Tip: Speak naturally and include specific values when dictating. For example, say "blood pressure one-twenty over eighty" rather than just "blood pressure was normal". This helps the AI extract precise observation values.