AI is transforming healthcare by reducing documentation burdens, improving communication, and enhancing patient care.

This guide provides practical strategies to leverage AI effectively in clinical workflows. You'll learn how AI can rewrite notes for clarity and compliance, summarize transcripts efficiently, and assist in patient communication.

To maximize the benefits, follow structured best practices for AI prompting, including defining clear roles, providing detailed instructions, specifying style guidelines, and avoiding inaccurate information.

By implementing these strategies, healthcare professionals can save time, improve accuracy, and focus more on patient care.

Note: This paper assumes that you can use your own AI prompts in your EMR to write or rewrite your medical documentation using a tool like AI Blaze.

Benefits of AI in Healthcare

The integration of AI into healthcare settings has revolutionized how medical professionals approach their daily tasks and patient care.

Here are the benefits of using AI in healthcare:

• More Efficient Workflows - AI automation reduces time spent on administrative tasks (like clinical notes), allowing healthcare providers to focus more time on direct patient care and complex medical decisions.

• Increased Accuracy in Documentation - AI systems can process and analyze large volumes of medical data with significantly fewer errors than manual review, leading to more accurate diagnoses and treatment plans.

• Reduced Human Error - By streamlining workflows and reducing human error, AI helps healthcare providers deliver more consistent and evidence-based care to their patients.

The implementation of AI in healthcare continues to evolve, offering new opportunities for improving both operational efficiency and patient care quality.

Examples of How AI is Used in Healthcare

Using AI helps healthcare professionals streamline documentation, note-taking, assessments, communication, and more.

Here are a few examples of how AI is used in healthcare:

1. Rewriting notes for clarity and compliance

Does this sound familiar? You meet with a patient and quickly jot down scrappy notes, only to spend your evening rewriting them.

Medical notes typically require revision to improve clarity and ensure compliance. AI can assist by rewriting, refining, and expanding content while ensuring accuracy.

2. Summarizing transcripts and notes

Doesn’t it seem a little redundant to tell the patient everything they need to know and then type the exact same thing?

AI can take raw transcripts, past notes, and any other information and automatically generate concise, well-structured summaries. This not only saves time but ensures consistency and completeness.

3. Responding to patient questions

If only patient communication were as simple as writing, "Take two aspirins and call me in the morning." Instead, healthcare providers must provide detailed, accurate, and compliant instructions.

AI can streamline this process by transforming key points into a complete, professional message, ensuring clarity, accuracy, and adherence to best practices in patient communication.

How to Make AI Work for You

To effectively use AI in healthcare, you need to draft prompts with clear and detailed instructions.

Here are a few best practices to quickly get the results you need:

1. Start with a clear role and task

Define the AI's role and specify the task upfront. This will create a framework for the AI and help ensure the output is not too far off base. The rest of the prompt, discussed in the following best practices, will fine-tune these instructions and improve the quality.

2. Provide a list of instructions with DO and DON’T examples

Clearly enumerate the instructions you’d like the AI to follow when drafting the response. Make each instruction clear, and, ideally, provide examples. If possible, also include negative examples (what NOT to write).

Refining positive and negative examples through iteration helps optimize the accuracy and effectiveness of AI-generated responses.

3. Specify language and style requirements

As part of your instructions, make sure to be specific about the language you’d like AI to use. If needed, include examples of specific words and phrases to use or not use.

4. Include, annotate and explain relevant data

Ensure the AI has all the required information to complete the task by including relevant patient information (name, age, etc.), transcripts, notes and labs that are needed for the task.

• Separate and highlight the context with a dedicated heading using the ## marks (## Heading)

• Annotate the beginning and ending of the context using triple quotation marks (“”” data “””)

• Explain the context and how it should be used.

5. Draft complete output examples

Help AI model the output by including one or more complete sample outputs in your prompts.

6. Instruct AI to avoid hallucinations

Unless instructed otherwise, AI may make up new information. Make sure you instruct the AI not to do so.

7. Iterate, iterate, iterate

Every time the AI produces an output that's not completely aligned with your expectations, add it along with the desired output as an example for one of the instructions. If it doesn't fit any of the instructions, add a new instruction.

Examples of Full Prompts

1. Turning scrappy notes into detailed SOAP notes

Prompt: You are a medical assistant tasked with refining and structuring clinical notes for clarity and compliance. Convert the following unstructured notes into a professional, well-organized format, following SOAP note guidelines.

Instructions

Follow these instructions when drafting the SOAP notes:

1. Organize the output into Subjective, Objective, Assessment, and Plan (SOAP) sections.

   • Subjective: includes information collected directly from the patient, including their chief complaint, history of present illness, pertinent medical history, and a current list of the patient’s medications.

   • Objective: objective information collected from the patient during the encounter, including: vital signs, physical exam notes, results of any other diagnostics.

   • Assessment: Short (one- to three-sentence) summary that includes the patient’s age, relevant medical history, major diagnosis and clinical stability. Include a differential diagnosis if applicable.

   • Plan: outline the next steps to treat the patient, including short- and long-term goals. See the sample output () below as an example.

2. Replace informal or vague language with precise medical terms.

   • Example: Do not use language like: "Pt c/o stomach pain, maybe an ulcer." Instead, use: ”Patient presents with persistent stomach pain, possibly indicative of an ulcer."

   • Example: Do not use language like: "Patient seems to have a bad stomach bug, feeling kind of sick.” Instead, use: "Patient presents with acute gastroenteritis symptoms, including nausea and diarrhea."

3. Fully expand medical abbreviations the first time they appear.

   • Example: "PT" --> "Physical Therapy (PT)."

4. Ensure the SOAP note is medically relevant, concise, and does not contain unnecessary details.

5. Only include information explicitly present in the provided notes. Do not infer or add medical details that are not stated.

   • Example: Do not use language like: "Patient likely has diabetes based on symptoms.” Instead, use: "Patient's lab results indicate elevated glucose levels, suggesting further evaluation for diabetes."

6. Refer to the patient as "the patient" instead of using their first names.

7. Maintain a neutral and professional tone. Use concise, clear, and direct language. Ensure proper grammar, spelling, and punctuation.

Clinical notes to rewrite

Below are notes taken by the physician that need to be rewritten as SOAP notes:

[Replace placeholder with clinical notes]

Relevant patient information to incorporate

Here is more information about the patient that can be used in the notes:

[Replace placeholder with patient information]

Sample output

Here is an example of what the output could look like.

Subjective: Patient presents with persistent headaches for the past two weeks, occurring primarily in the morning. Reports occasional dizziness but denies nausea or vomiting.

Objective: Blood pressure 120/80 mmHg. No neurological deficits noted. Pupils equal, round, and reactive to light.

Assessment: Likely tension-type headache. Differential includes migraine and sinus headache.

Plan:

1. Recommend over-the-counter NSAIDs for pain relief.
2. Encourage adequate hydration and sleep hygiene.
3. Follow-up in two weeks if symptoms persist or worsen.
4. Consider imaging if headaches become more severe or are accompanied by neurological symptoms.

2. Responding to a patient question incorporating provider instructions

Prompt You are assisting with patient communication on behalf of a healthcare provider. Your task is to craft a professional, empathetic, and medically accurate response based on the provider’s instructions and the patient’s original message.

Instructions

Follow these instructions:

1. Acknowledge the patient's concern: Begin the response by recognizing the patient's question or concern to create a compassionate and engaging interaction.

   • Example: "I understand that missing a dose of your medication can be concerning."

2. Provide clear and direct medical guidance: Ensure that the response is straightforward and accurately reflects the provider's instructions.

   • Example: "Do not take a double dose. Instead, resume your normal schedule tomorrow."

3. Use professional and reassuring language: Maintain a professional yet empathetic tone to make the patient feel supported.

   • Example: Instead of "It’s probably fine, just take your meds tomorrow," use "Please resume your regular schedule tomorrow. If you have concerns, we are here to help."

4. Avoid adding unverified medical information: Only include details explicitly stated by the provider. Do not infer or provide additional medical advice beyond what is given.

   • Example: Instead of "This should not affect your health," use "Please monitor for any unusual symptoms and contact us if needed."

5. Ensure proper structure and readability: Format the message in a way that is easy for the patient to understand, avoiding complex medical jargon unless necessary. Use clear and concise language.

6. Refer to the patient by their last name

   • Example: Instead of "Dear John," use "Dear Mr Smith,"

Conversation thread

Here is the conversation thread between the provider and patient:

[Replace placeholder with conversation history]

Last patient message

Here is the patient’s last message, to which this is the response:

[Replace placeholder with last message from patient]

Provider instructions

These are the rough notes typed by the provider that should be incorporated into the message.

[Replace placeholder with raw instructions from the provider]

Example of full output

Below is an example of what the output should look like "Dear Mr. Smith,

Thank you for reaching out. Please do not double your dose tonight. Instead, resume your regular schedule tomorrow. In the meantime, continue monitoring your blood pressure, and let us know if you experience any symptoms such as dizziness or headaches. Feel free to contact us if you have further concerns.

Best, Dr. Smith"

Give it a try!

AI can significantly reduce your documentation time so you can focus on your patients. Start simple and iterate to improve results gradually.