Mastering EncompassScribe Workflows

Review these guidelines to gain a basic understanding of EncompassScribe:

• EncompassScribe is trained on conversations between providers and patients. Don’t try to give instructions to or navigate with EncompassScribe.
• You can create multiple recordings within a single visit. However, you can reconcile (approve) the AI output only once per visit.
• EncompassScribe captures only what you say. Every piece of data is extracted from the visit transcript. If you don't say it aloud, it won't be documented. EncompassScribe cannot see you point or gesture. EncompassScribe does not make clinical decisions for you.
• Laterality is important, so overstate where you are looking or what you are discussing.
• Diagnoses are the main anchor points. Plans are added to diagnoses to build the note.

The following buttons help you navigate through EncompassScribe:

•  Record Visit opens the recorder.
•  (Record) starts the real-time transcription.
•  (Pause) pauses the recording and allows resuming the recording without reconsenting.
•  (Stop) stops the recording and generates the AI output that you will review and approve in the Reconciliation screen.
•  (Close) cancels the recording and closes the recorder—no AI output is generated.
•  View AI Output and  Output Ready opens the Reconciliation screen.
• Reconcile pushes the output accepted in the Reconciliation screen into the Visit Overview.

There are two approaches to verbalizing your visits:

1. Natural conversation. You are able, and encouraged, to speak naturally to your patient. EncompassScribe has been trained to focus only on clinically relevant information.
2. Dictation. If you prefer, you can use EncompassScribe at the end or after the visit without conversation, similar to dictation.

With either workflow, EncompassScribe performs best with the following structure in mind (think SOAP note):

• Exam and findings
• Diagnosis #1
  • Discussion: explain the diagnosis, review supporting tests/imaging
  • Plan: review your plan and recommendations (observation, medications, procedures, etc.)
• Diagnosis #2
  • Discussion: explain the diagnosis, review supporting tests/imaging
  • Plan: review your plan and recommendations (observation, medications, procedures, etc.)
• Follow-up

• Slit lamp is always on.
• Don’t forget about laterality.

  For example, “In the right eye, there’s 2+ NS and 1+ cortical, and it looks like 3+ NS in the left eye.”

• Verbalize “Right only” or “Left only” to include only that eye. This is a good tactic for unilateral postop exams.
• Say “dilate” or “dilated” to turn on dilation. Without verbalizing dilation, you can still mention posterior findings, which will be captured as undilated.

  For example, "C/D ratio or undilated macula."

• If “normal,” “quiet,” etc., or nothing is verbalized, your default normal findings will populate the exam.

EncompassScribe is trained with simple terms and synonyms. However, being more specific is better to reduce ambiguity.

• An AI-generated diagnosis summary is automatically produced with each diagnosis.
• Counseling plans are predicted when a diagnosis is further discussed with the patient.
• Mention imaging plans in context of the parent diagnosis. EncompassScribe needs to know which diagnosis to link the plans to.

  “You have Dry AMD in both eyes. The retina scan today showed drusen in both eyes which is consistent with your Dry AMD.”

  “We repeated your visual field today to track the progression of your primary glaucoma…”

• Specificity is recommended for close or ambiguous plans (for example, permanent punctal plugs vs. temporary).
• EncompassScribe will document something you did today versus something to be scheduled, provided you verbalize timeframes.

  “That PCO looks like it’s bothering you and we can help. We will see you back in 2 weeks and perform the YAG laser at that visit.”

• You can easily identify which text boxes, check boxes, and drop-downs can be populated by EncompassScribe. Look for the AI icons scattered throughout Encompass to get a sense of which fields will be populated by EncompassScribe.

  

• Prescription Medication Management and OTC Treatment Regimen plans are brief AI-generated summaries of prescription medications and OTC recommendations managed in the current visit and linked to diagnoses. These plans, if you accept them, contribute to suggested billing codes.
• Medication prescriptions are automatically generated when a prescription is started, continued, or modified.
• There are two approaches to verbalizing prescriptions:
  • Direct capture. Verbally specify all of the details (sig), and EncompassScribe will capture them for you.

    For example, “1 drop in the right eye twice a day.”

  • Enrichment. Mention the medication only (e.g., "latanoprost"), and EncompassScribe will automatically populate your last, or most commonly used, sig (e.g., 1 drop in both eyes every evening at bedtime).

EncompassScribe suggests visit documentation based on your verbalizations. Here are general examples of things you can say.

Phrase	EncompassScribe Action
“dilated” or “dilation”	Turns on the dilation portion of the exam
“right only” or “left only”	Turns off the contralateral eye in the exam
Any discussion regarding a diagnosis	Suggests a counseling plan for that diagnosis
“prescription” or “send to the pharmacy”	Suggests a prescription plan
“OTC” or “over-the-counter”	Suggests an OTC plan

The following tables list common diagnoses and examples of colloquial phrases that EncompassScribe can recognize and translate into suggested visit documentation.

Refractive Errors

Diagnosis	Potential Phrase
astigmatism	corneal astigmatism football shaped cornea bend of the cornea distorted cornea
hyperopia	farsighted long-sighted
myopia	nearsightedness nearsighted myopic
presbyopia	age-related farsightedness loss of accommodation

Cornea, Ocular Surface, and External Disease

Diagnosis	Potential Phrase
allergic conjunctivitis	eye allergy allergic pink eye seasonal conjunctivitis allergic eye inflammation
blepharitis	inflamed eyelids eyelid inflammation lid margin disease inflammation of the eyelid margin
dry eye syndrome	dry eye
keratoconjunctivitis sicca	k sicca
meibomian gland dysfunction	meibomian gland disease oil glands not working dysfunctional oil glands

Cataract, Lens, and Postsurgical

Diagnosis	Potential Phrase
combined form of senile cataract	mixed cataracts combined cataracts combined type of cataract
nuclear cataract	nuclear cataract
posterior capsular opacification	scar tissue behind the lens film behind the lens opacity behind the lens secondary cataract PCO
postop cataract	status post cataract surgery
pseudophakia	artificial lens lens implanted IOL already had cataract surgery

Glaucoma and Optic Nerve

Diagnosis	Potential Phrase
glaucoma suspect	glaucoma suspect
ocular hypertension	high eye pressure elevated eye pressure eye pressure above normal
primary open-angle glaucoma (POAG)	POAG open-angle glaucoma

Macula and Retina

Diagnosis	Potential Phrase
choroidal nevus	retinal freckle retinal nevus mole in the retina
dry macular degeneration	dry AMD geographic atrophy macular degeneration
epiretinal membrane	cellophane maculopathy retinal wrinkle membrane in the retina film across the back of the eye
wet macular degeneration	wet AMD exudative AMD neovascular AMD neovascular macular degeneration

Systemic Disease and Vascular Retinopathy

Diagnosis	Potential Phrase
hypertensive retinopathy	high blood pressure retinopathy blood pressure related retinal changes blood pressure retinopathy
proliferative diabetic retinopathy	PDR diabetic retinal neovascularization neovascular diabetic retinopathy
type II diabetes without complication	diabetes without ocular involvement no diabetes in the eye diabetes without eye involvement no diabetic retinopathy

Vitreous

Diagnosis	Potential Phrase
posterior vitreous detachment	PVD vitreous detachment jelly detachment vitreous separation
vitreous floaters	floaters vitreous opacities vitreous debris

The following table lists common plans and examples of colloquial phrases that EncompassScribe can recognize and translate into suggested visit documentation.

Desired Plan	Potential Phrases	Example with Context
counseling (any diagnosis)	No specific “buzz” or “trigger” words	Discussion of the clinical nature of diagnosis or treatment options should trigger counseling
refraction	Glasses check, prescription check	“We performed a refraction today.” “We’ll update your glasses.”
OCT, retinal	Mac OCT, retina scan, back of the eye scan	“We got a scan of the back of your eye.” “Let’s look at a scan of your retina.”
fundus photos	Retinal photos, retinal pictures	“Let’s get some photos of your retina.” “We took some baseline retinal photos today.”
OCT, optic nerve	Nerve OCT, RNFL, optic nerve scan	“Let’s look at your optic nerve scan.” “Your optic nerve scan today showed…”
automated perimetry	Visual field, HVF, peripheral vision test	“Let’s review your visual field test.” “Let’s repeat that visual field.”
optical biometry	A-scan, IOL master, biometric, Argos, Lenstar	“We got some cataract measurements today.” “I’ll show you your Argos test to review.”
glaucoma assessment	glaucoma summary, glaucoma status	“Let’s review the status of your glaucoma.” “Overall, the status of your glaucoma is…”
YAG capsulotomy	YAG caps, laser polishing procedure	“We’ll perform laser polishing to take care of that film behind the lens.”
intravitreal injection	Eylea injection, Vabysmo injection, Lucentis injection, etc.	“We’ll do an injection of Avastin today.” “Let’s proceed with a Lucentis injection today.”
temporary vs. permanent plugs	temporary, permanent	“These plugs are designed to stay in.” “These plugs are temporary and dissolve over time.”
IVFA (Fluorescein)	Fluorescein, FA	“We’ll run a special dye test.” “Let’s get that dye test to look at the vessels.”
epilation	remove eyelash with forceps	“We’ll remove those lashes with some forceps.” “I’m happy to remove those lashes today.”
B-scan	B-scan, eye ultrasound	“We’ll get a quick ultrasound of the eye.” “It looks like the ultrasound is stable.”
corneal topography	topos, corneal map	“We got a topographic map of your corneas.” “Your corneal topos look stable.”
selective laser trabeculoplasty	SLT	“We’ll do the SLT laser today.” “This laser will help lower the eye pressure.”
order for surgery	order for surgery, sign up for surgery	“We’ll get you signed up for surgery.” “We’ll get you scheduled for cataract surgery.”