O1
AI Draft
Phase I - Learning Your Resources
start
GOALS
Know the difference between the AI draft and a Draft Note
Be introduced to the AI Draft in detail
Learn where the AI Draft can be tricky, and practice solutioning!
Understand how to use the AI draft appropriately
Play
Be sure to participate fully -- always click on any slide with an interactive mark/area.
Know the best practices for using the AI Draft
Info
Quick Review
DAX Studio has multiple note sections that you will document in
Review of Systems
History of Present Illness
Physical Examination
Results
Social History
Procedure
Family History
Assessment & Plan
Allergies
Attestation
Internal Information
Current Medications
Immunizations
Review of DAX Studio best practices
- Utilize iPhrases and the Clinician Instructions
- Document in the appropriate section
- NEVER assume that a draft which populates is accurate. It is your responsibility to listen, insert the appropriate iPhrase, and edit the draft.
Grab these DAX Studio guides for further assistance!
Info
introduction
What is the AI Draft
start
intro
What is aN ai draft note?
An ai draft note is text that was written by the ai it autopopulates in the note section as well as the ai draft tab
Great, you may be thinking. My job is done! Not so fast!
Why not?
be careful of...
edited by
Written by
YOU
The AI
You are the first and the last line of defense in ensuring quality documentation
These generic Drafts will not account for the Clinician Instructions, to include formatting and use of iPhrases Every section within the Note tab will always populate in paragraph format.
Not editing the AI draft results in sending an inaccurate note to the clinician and could lead to patient harm.
LISTEN - IPHRASE - EDIT
Where do I find the ai draft
start
DAX Studio - ai draft tab
You can see that the headings in the AI draft tab look slightly different
The draft will populate in the ai draft tab You may need to use the right arrow to scroll past the transcript, iphrase preview, and instructions
Text will always be in paragraph form in the AI Draft Tab and in the Note Section.
You will see some of the other headings in the AI Draft Note. They may or may not have information in them.
Tips
the note section
Just like the AI Draft in the AI Draft Tab, the draft that populates in the Note Section is in paragraph format. It has not been reviewed for grammar, sentence structure, hallucinations or accuracy.
Do not EVER submit this draft note as your final note for the EHR
so How do i use the ai draft
continue
step 1
Failure to use the iPhrase means formatting and content issues...
identify the iphrase needed & Insert it
Listen to the first 30-60 seconds of the recording and identify which iPhrase is to be used for this encounter Remember: the AI draft will NOT automatically insert the iPhrase
...and less clinician satisfaction
more info
step two & three
3. organize
2. listen & Edit
Listen to the entire recording from start to finish Have the clinician instructions pulled up as you begin to edit Ensure all information is correct Assess for grammar, sentence structure and punctuation. Ex: The AI draft is notorious for starting each sentence identically!
You already know which iPhrase is going to be used, and have it inserted. Now, your note has been thoroughly edited and adheres to all our standards. Move the information from where it is/was in the AI draft and place it into the correct part of the iPhrase. As you begin to grow more and more comfortable with editing, you will begin to be able to do these two steps simultaneously.
Workflow
Check what you know
go!
Question 1/3
Test
I glanced at the AI draft as I listened to most of the encounter. Is this okay?
"Glancing" at and listening to "most" of the encounter are not fulfilling your responsibilities.
No problems with that; you technically reviewed and listened.
As long as you listened and added anything omitted, you are fine.
Test
Question 2/3
The AI draft noted that the patient being seen by an orthopedic clinician was married and did lots of repetitive motion at their job. What was actually said was different, noting that the patient was a veterinarian who did lots of repetitive motion at their job. Why is this a critical mistake?
It's not that big a deal, it wouldn't impact the patient or his potential treatment.
His occupation and the repetitive motions could have something to do with his chief complaint
It doesn't make sense
Question 3/3
Test
Why shouldn't I just take the AI Draft and paste it into the EHR?
The draft may contain numerous errors ranging in severity from made up words to hallucinations to incorrect diagnoses to minor grammatical errors. Pasting the note without reviewing it is unacceptable.
It should be ok if you've listened to at least 90% of the encounter and edited whatever was in the draft.
This is best practice and how everyone should do it.
Best practices
AI Draft
continue
Best Practices
- Do not delete the draft and type the encounter yourself
- Thoroughly and completely edit the encounter
- Always listen to the encounter from beginning to end
No detail is too small!
Utilize Microsoft Editor to help with your proofreading
Use critical thinking skills -- is the context of what you are seeing matching what you are hearing?
Tips
Workflow
arrange the elements in their corresponding order
A. Ensure abberations/hallucinations have been removed
B. Review the iPhrases
C. Select the appropriate iPhrase
D. Listen to the entire recording, editing appropriately
E. Review the Clinician Instructions
F. Proofread
check
The impact of the ai draft
on DAX Studio
start
Why does the ai draft matter so much, anyway?
Ensuring the AI draft has been appropriately edited and organized enables other functions of DAX Studio to function more efficiently
These are REAL people! Not properly editing and reviewing could directly impact their well being.
We promise our clinicians that we will deliver a note as good as they would write themselves -- failing to do our due diligence means we are not doing our jobs
Like the delivery tab, which is where the note is copied & pasted into the EHR from!
Failure to follow these guidelines, and to use the Instructions and iPhrases appropriately will result in clinician escalations and dissatisfaction. Continued issues could potentially impact your employment as well.
If the information in the AI draft was not properly edited and reviewed, the delivery tab information will be wrong -- and so will the final note.
Question 1/3
review 1
A clinician is going to complain if they want to complain; there isn't anything that I can do to make it better.
flip card
Question 1/3
review 1
Mistakes that clinicians escalate are all too often AVOIDABLE - including things like not using iPhrases, poor grammar and sentence structure, and having to reorganize the note.
i didn't know... i will try again
i knew it! let's move foward
2/3
review 2
I am expected to listen to the encounter , and edit .
flip card
closure/summary
2/3
review 2
I am expected to listen to the encounter completely, and edit thoroughly.
i didn't know... i will try again
i knew it! let's move foward
closure/summary
3/3
review 3
Missing a detail, or keeping in something the AI draft noted which is incorrect is not actually that big a deal.
flip card
3/3
review 3
- The kind of mistakes we discussed here today are AVOIDABLE mistakes and reflect poorly.
- These mistakes could impact the patient's health and safety
- They will decrease clinician satisfaction and increase escalations
let's move foward
tricky Examples & Practice
AI Draft
continue
tricky example - verbatim text
- The AI paragraphs are typed as the AI hears the patient explanation which means there can be a lot of extra information that can be consolidated and made less wordy.
- Sentences can be repetitive if the patient notes the same information again.
- The AI will also pick up text from the provider when they explain their personal life or chat with the patient, but it picks it up as if the patient is noting this for themselves.
Wordiness
He states that his mother lived to be 95 years old. He states that she had Alzheimer's, and it only was bad the last 2 to 3 years of her life. He states that at that point, they could deal with it but it was not easy. He states that they put her in an Alzheimer's home.
His mother, who had Alzheimer's, lived to be 95 years old. She was placed in an Alzheimer's home as her symptoms worsened in the final 2 to 3 years of her life; he notes it was not an easy time.
repetition
He reports it is not less than 1 out of 10 with it going all the way to 5 our of 10 at its worst. For the most part, the pain is at a 1 out of 10.
He reports pain is primarily a 1 out of 10 on the pain scale with a 5 out of 10 when it is most severe.
speaker confusion
The historian states that the patient's cholesterol was a little low and wants to double up on her dose of pravastatin.
The historian enquires about the patient's low cholesterol, as my medical assistant told him about it and wanted him to double the patient's pravastatin.
Now you try
examples
hallucinations
Examples
She complains of a pain about her left biceps that’s been ongoing. For years she denies any recent injury.
The medical marijuana helps. She also uses the medical marijuana cream, which makes a lot of pain.
When the AI Draft does not understand something completely, it tends to hallucinate. These sentences can be garbled, and often do not make sense.
I discussed with the patient that he should patient said that he has a appointment with Dr. X for facet injections at upper level.
He does have OT order local to him to. They have not gotten filled yet where he can work on formal therapy."
Check what you know
accompanying person
AI Draft: "She is accompanied by an interpreter."
The accompanying person can often be misgendered or misidentified
What needed to be documented: "She is accompanied by her partner. The language interpreter services were utilized for the duration of today's visit."
medical terminology
The AI draft can fail to upgrade medical terminology appropriately
"She denies redness or swelling."
"She denies erythema or edema."
It can also upgrade the term incorrectly
"He has never had a bone break."
Example AI Draft: "The patient has moderate parotid artery stenosis."
"He denies a history of fractures."
Correct documentation: "The patient has moderate carotid artery stenosis."
Made up words/grammar issues
Error text: briefly experienced cysts, but they recur. Every now then, would have cysts. thighs full of well. received old, by time 12, had experienced them. At time, taking antibiotics.
Correction text: She experienced pimples in the genital and thigh area at age 12 and was given antibiotics. They have recurred intermittently since.
Error text: yers Corrected text: beers
be sure to also watch out for...
background noise
The AI Draft can struggle to "hear" when there is background noise and might return a draft that is several lines long, while the encounter is 15-20 minutes or more.
ALWAYS listen thoroughly & edit appropriately!
it is imperative we follow the clinician instructions and the DQS for documenting the Assessment & Plan. Be sure to check out our Assessment & Plan module for tips, tricks, and best practices.
date hallucinations
The AI Draft often uses 2022 even when the transcript and the clinician both note 2023. This can be easy to miss -- so be careful & pay close attention in your editing.
Demonstration
Play
Let's see how all that we have learned so far continues to work together!
AI Draft quiz!
Now let's take a brief quiz to review what you have learned today! You must clear the quiz with a score of 80% or better to move on to the next module! Take your time, don't stress, and try to implement what you have learned. Best of luck to you!
CLICK TO BEGIN
Download me for later!
Thank you for completing your Phase I AI Draft Module!
For questions or concerns regarding Phase I of your Training, please reach out to Nikki Dease on Teams or Nikki.dease@cognizant.com
Use your resources!
Your clinician and the patient count on you to:
- Review, understand and utilize the Clinician Instructions
- Use the iPhrase preview to confirm you are selecting the appropriate/best iPhrase
More best practices
Use your DAX Studio shortcuts & tools, like the play and pause, and the rewind shortcuts!
- Work with the Clinician Instructions open and toggled to the section that you are currently working in. This saves time when you are comparing the draft and iPhrase and organizing your note.
Errors...
...that have made it into the EHR
Errors such as these decrease the efficiency of our product leading to client disatissfaction, and could cause harm to the patient.
- AI draft wrote “diffuse leg changes about the cervical spine”; QDS kept this verbatim. Actually was “diffuse spondylitis changes about the cervical spine.”
- "She said that it the spasm began about 7 months ago and improved two 3 months ago."
- “Golf keeper” instead of “goal keeper” kept in HPI – this was how the patient sustained the injury
AI Draft - Phase I - Learning Your Resources
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Created on October 31, 2023
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Transcript
O1
AI Draft
Phase I - Learning Your Resources
start
GOALS
Know the difference between the AI draft and a Draft Note
Be introduced to the AI Draft in detail
Learn where the AI Draft can be tricky, and practice solutioning!
Understand how to use the AI draft appropriately
Play
Be sure to participate fully -- always click on any slide with an interactive mark/area.
Know the best practices for using the AI Draft
Info
Quick Review
DAX Studio has multiple note sections that you will document in
Review of Systems
History of Present Illness
Physical Examination
Results
Social History
Procedure
Family History
Assessment & Plan
Allergies
Attestation
Internal Information
Current Medications
Immunizations
Review of DAX Studio best practices
Grab these DAX Studio guides for further assistance!
Info
introduction
What is the AI Draft
start
intro
What is aN ai draft note?
An ai draft note is text that was written by the ai it autopopulates in the note section as well as the ai draft tab
Great, you may be thinking. My job is done! Not so fast!
Why not?
be careful of...
edited by
Written by
YOU
The AI
You are the first and the last line of defense in ensuring quality documentation
These generic Drafts will not account for the Clinician Instructions, to include formatting and use of iPhrases Every section within the Note tab will always populate in paragraph format.
Not editing the AI draft results in sending an inaccurate note to the clinician and could lead to patient harm.
LISTEN - IPHRASE - EDIT
Where do I find the ai draft
start
DAX Studio - ai draft tab
You can see that the headings in the AI draft tab look slightly different
The draft will populate in the ai draft tab You may need to use the right arrow to scroll past the transcript, iphrase preview, and instructions
Text will always be in paragraph form in the AI Draft Tab and in the Note Section.
You will see some of the other headings in the AI Draft Note. They may or may not have information in them.
Tips
the note section
Just like the AI Draft in the AI Draft Tab, the draft that populates in the Note Section is in paragraph format. It has not been reviewed for grammar, sentence structure, hallucinations or accuracy.
Do not EVER submit this draft note as your final note for the EHR
so How do i use the ai draft
continue
step 1
Failure to use the iPhrase means formatting and content issues...
identify the iphrase needed & Insert it
Listen to the first 30-60 seconds of the recording and identify which iPhrase is to be used for this encounter Remember: the AI draft will NOT automatically insert the iPhrase
...and less clinician satisfaction
more info
step two & three
3. organize
2. listen & Edit
Listen to the entire recording from start to finish Have the clinician instructions pulled up as you begin to edit Ensure all information is correct Assess for grammar, sentence structure and punctuation. Ex: The AI draft is notorious for starting each sentence identically!
You already know which iPhrase is going to be used, and have it inserted. Now, your note has been thoroughly edited and adheres to all our standards. Move the information from where it is/was in the AI draft and place it into the correct part of the iPhrase. As you begin to grow more and more comfortable with editing, you will begin to be able to do these two steps simultaneously.
Workflow
Check what you know
go!
Question 1/3
Test
I glanced at the AI draft as I listened to most of the encounter. Is this okay?
"Glancing" at and listening to "most" of the encounter are not fulfilling your responsibilities.
No problems with that; you technically reviewed and listened.
As long as you listened and added anything omitted, you are fine.
Test
Question 2/3
The AI draft noted that the patient being seen by an orthopedic clinician was married and did lots of repetitive motion at their job. What was actually said was different, noting that the patient was a veterinarian who did lots of repetitive motion at their job. Why is this a critical mistake?
It's not that big a deal, it wouldn't impact the patient or his potential treatment.
His occupation and the repetitive motions could have something to do with his chief complaint
It doesn't make sense
Question 3/3
Test
Why shouldn't I just take the AI Draft and paste it into the EHR?
The draft may contain numerous errors ranging in severity from made up words to hallucinations to incorrect diagnoses to minor grammatical errors. Pasting the note without reviewing it is unacceptable.
It should be ok if you've listened to at least 90% of the encounter and edited whatever was in the draft.
This is best practice and how everyone should do it.
Best practices
AI Draft
continue
Best Practices
No detail is too small!
Utilize Microsoft Editor to help with your proofreading
Use critical thinking skills -- is the context of what you are seeing matching what you are hearing?
Tips
Workflow
arrange the elements in their corresponding order
A. Ensure abberations/hallucinations have been removed
B. Review the iPhrases
C. Select the appropriate iPhrase
D. Listen to the entire recording, editing appropriately
E. Review the Clinician Instructions
F. Proofread
check
The impact of the ai draft
on DAX Studio
start
Why does the ai draft matter so much, anyway?
Ensuring the AI draft has been appropriately edited and organized enables other functions of DAX Studio to function more efficiently
These are REAL people! Not properly editing and reviewing could directly impact their well being.
We promise our clinicians that we will deliver a note as good as they would write themselves -- failing to do our due diligence means we are not doing our jobs
Like the delivery tab, which is where the note is copied & pasted into the EHR from!
Failure to follow these guidelines, and to use the Instructions and iPhrases appropriately will result in clinician escalations and dissatisfaction. Continued issues could potentially impact your employment as well.
If the information in the AI draft was not properly edited and reviewed, the delivery tab information will be wrong -- and so will the final note.
Question 1/3
review 1
A clinician is going to complain if they want to complain; there isn't anything that I can do to make it better.
flip card
Question 1/3
review 1
Mistakes that clinicians escalate are all too often AVOIDABLE - including things like not using iPhrases, poor grammar and sentence structure, and having to reorganize the note.
i didn't know... i will try again
i knew it! let's move foward
2/3
review 2
I am expected to listen to the encounter , and edit .
flip card
closure/summary
2/3
review 2
I am expected to listen to the encounter completely, and edit thoroughly.
i didn't know... i will try again
i knew it! let's move foward
closure/summary
3/3
review 3
Missing a detail, or keeping in something the AI draft noted which is incorrect is not actually that big a deal.
flip card
3/3
review 3
let's move foward
tricky Examples & Practice
AI Draft
continue
tricky example - verbatim text
Wordiness
He states that his mother lived to be 95 years old. He states that she had Alzheimer's, and it only was bad the last 2 to 3 years of her life. He states that at that point, they could deal with it but it was not easy. He states that they put her in an Alzheimer's home.
His mother, who had Alzheimer's, lived to be 95 years old. She was placed in an Alzheimer's home as her symptoms worsened in the final 2 to 3 years of her life; he notes it was not an easy time.
repetition
He reports it is not less than 1 out of 10 with it going all the way to 5 our of 10 at its worst. For the most part, the pain is at a 1 out of 10.
He reports pain is primarily a 1 out of 10 on the pain scale with a 5 out of 10 when it is most severe.
speaker confusion
The historian states that the patient's cholesterol was a little low and wants to double up on her dose of pravastatin.
The historian enquires about the patient's low cholesterol, as my medical assistant told him about it and wanted him to double the patient's pravastatin.
Now you try
examples
hallucinations
Examples
She complains of a pain about her left biceps that’s been ongoing. For years she denies any recent injury.
The medical marijuana helps. She also uses the medical marijuana cream, which makes a lot of pain.
When the AI Draft does not understand something completely, it tends to hallucinate. These sentences can be garbled, and often do not make sense.
I discussed with the patient that he should patient said that he has a appointment with Dr. X for facet injections at upper level.
He does have OT order local to him to. They have not gotten filled yet where he can work on formal therapy."
Check what you know
accompanying person
AI Draft: "She is accompanied by an interpreter."
The accompanying person can often be misgendered or misidentified
What needed to be documented: "She is accompanied by her partner. The language interpreter services were utilized for the duration of today's visit."
medical terminology
The AI draft can fail to upgrade medical terminology appropriately
"She denies redness or swelling."
"She denies erythema or edema."
It can also upgrade the term incorrectly
"He has never had a bone break."
Example AI Draft: "The patient has moderate parotid artery stenosis."
"He denies a history of fractures."
Correct documentation: "The patient has moderate carotid artery stenosis."
Made up words/grammar issues
Error text: briefly experienced cysts, but they recur. Every now then, would have cysts. thighs full of well. received old, by time 12, had experienced them. At time, taking antibiotics.
Correction text: She experienced pimples in the genital and thigh area at age 12 and was given antibiotics. They have recurred intermittently since.
Error text: yers Corrected text: beers
be sure to also watch out for...
background noise
The AI Draft can struggle to "hear" when there is background noise and might return a draft that is several lines long, while the encounter is 15-20 minutes or more.
ALWAYS listen thoroughly & edit appropriately!
it is imperative we follow the clinician instructions and the DQS for documenting the Assessment & Plan. Be sure to check out our Assessment & Plan module for tips, tricks, and best practices.
date hallucinations
The AI Draft often uses 2022 even when the transcript and the clinician both note 2023. This can be easy to miss -- so be careful & pay close attention in your editing.
Demonstration
Play
Let's see how all that we have learned so far continues to work together!
AI Draft quiz!
Now let's take a brief quiz to review what you have learned today! You must clear the quiz with a score of 80% or better to move on to the next module! Take your time, don't stress, and try to implement what you have learned. Best of luck to you!
CLICK TO BEGIN
Download me for later!
Thank you for completing your Phase I AI Draft Module!
For questions or concerns regarding Phase I of your Training, please reach out to Nikki Dease on Teams or Nikki.dease@cognizant.com
Use your resources!
Your clinician and the patient count on you to:
More best practices
Use your DAX Studio shortcuts & tools, like the play and pause, and the rewind shortcuts!
Errors...
...that have made it into the EHR
Errors such as these decrease the efficiency of our product leading to client disatissfaction, and could cause harm to the patient.