Verbalizing Visit Documentation

This page provides tips for speaking so EncompassScribe can most accurately document your exams.

Speaking to EncompassScribe takes practice. Even if you already communicate well with your patients, you're probably using both verbal and nonverabal cues to ensure your patients understand. Those nonverbal cues, like hand gestures and intonation, streamline personal communications, but aren't accessible to EncompassScribe. Fortunately with a little practice you can quickly learn to speak so EncompassScribe can understand your specific intentions. You might even find that this helps improve your communication with patients, too.

When working with EncompassScribe, effective communication is key to ensuring accurate and complete documentation. Basically, if you would document it, you need to say it. To help you get the most out of this tool, here are some revised guidelines specifically for optometrists.

EncompassScribe was trained on English-based language libraries developed by practicing eyecare providers, to help capture efficient and relevant notes.

Tips for Verbalizing Visits

Capture Quality Recordings

To ensure the EncompassScribe captures everything correctly, prioritize a clear and quiet environment.

  • Minimize noise. Avoid noisy spaces and cross-conversations.
  • Pause for sidebars. When you need to have a private discussion with a staff member or make a personal call, pause the listening.

Use Specific Diagnoses

Be as precise as possible when stating a diagnosis to support accurate documentation.

  • Be precise. Instead of broad terms like "glaucoma suspect," verbalize precise diagnoses like "primary open-angle glaucoma" or "normal tension glaucoma."
  • Specify the condition. Mention specific conditions like "anterior uveitis" instead of just saying "eye inflammation."

Verbalize Eye and Location

Always specify which eye and location you are referring to when discussing a condition. If you'd have to tap it in the app, you'll need to verbalize it.

  • Specify eye. When discussing each condition or treatment, state whether it's the right eye, left eye, or both eyes.
  • Specify associate diagnoses. If you verbalize multiple diagnoses, they will be listed separately.

    Example: "The patient shows signs of diabetes mellitus with an associated diagnosis of diabetic retinopathy in both eyes."

  • State locations clearly. Clearly state the specific location within the eye, for example, "inferior retinal detachment" or "temporal pterygium."

Use Patient-Friendly Terms

Help the patient understand their condition by explaining it in simple terms.

  • Explain clearly. Explain complex conditions using simple terms.

    Example: Instead of "conjunctivitis," you could say "pink eye." Synonyms are acceptable as long as they are specific to the condition.

Communicate Plans Clearly

Clearly verbalize your plan for the patient's care during the visit.

  • Mention your plan. Always state your plan, whether it's prescribing glasses, ordering diagnostic tests, or scheduling a follow-up.
  • Specify treatment. Specify the type of treatment or method being used, like "YAG laser capsulotomy" or "in-office punctal plugs."

Order Tests Explicitly

Clearly mention any specific diagnostic or imaging tests you are ordering.

  • Mention tests. Clearly mention the specific tests you are ordering, like "visual field test for glaucoma" or "OCT scan of the macula".

Prescribe Medications with Details

When prescribing, state all the necessary details to ensure a complete and accurate prescription.

  • Describe the details. State the medication name, strength, dosage instructions (sig), quantity, and refill information. For example, "Lumigan 0.01% eye drops, apply one drop in each eye once before bed, 2.5 mL bottle with six refills."

Verbalize Follow-Up Instructions

Clearly outline the follow-up plan for the patient.

  • State a clear plan. Clearly state the follow-up plan for the patient For example, "Come back in 6 months for a dilated eye exam to recheck your diabetic retinopathy").

Things to Avoid When Talking to EncompassScribe

Avoid Broad Terms

To support accurate clinical documentation, avoid using vague or nonspecific descriptions.

  • Be specific. Do not use vague descriptions like "vision problem." Be specific by saying "unstable astigmatism."

Don't Assume AI Understands Context

Remember that EncompassScribe cannot interpret nonverbal cues.

  • Be explicit. Unlike a human scribe, EncompassScribe cannot see or interpret nonverbal cues. Always be explicit in your verbal descriptions. For example, pointing to an eye won't work; you must say "right eye."

Do Not Skip Medication Details

Critical details are necessary for a complete prescription.

  • Complete prescriptions. Avoid omitting critical details like medication strength or quantity, as this can lead to incomplete prescriptions.

Don’t Forget to Mention Locations

EncompassScribe needs a clear location for a condition to be documented accurately.

  • Explicit locations. Don't assume EncompassScribe will know the location of a condition without you explicitly stating it. For example, state "temporal retina" or "superior sclera."

Don't Generalize Diagnoses

To prevent confusion, avoid using nonspecific diagnoses or jargon.

  • Be precise. Avoid using vague or nonspecific diagnoses like "dry eyes" or "refractive error." Use precise terms, like "moderate to severe dry eye syndrome" or "myopic astigmatism."

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