Changing Default Scribes: It’s as Easy as 1-2-3!
Need to switch scribes mid-consult? Here’s how you can change your default scribe in a few simple steps:
- Start Your Consult 📋
Once your consult begins, look along the bottom of the screen. Tap on the third button to see the currently selected scribe.
- View Scribe Options 👓
The button will show the scribe currently in use (e.g., the H&E, A, P template). The time displayed beside it offers a suggested template based on the consult duration so far.
- Select a New Scribe 📝
Tap the button to view the list of available scribes. This list will continue to expand as new options are added. If you have any suggestions for scribes, let us know!
Customising scribes to your specific needs!
Want to customise your scribes? Here’s how you can customise your scribes in a few simple steps: Check out this loom to watch Casey fumble his way through creating a new ai scribe
Keep in touch as we build our template builder which will help you build your own templates with intelligent suggestions
Why Change My Note Type?
Switching the note type adjusts how MBSPro structures your documentation, essentially changing the instructions given to the system. This adaptability allows you to tailor your notes to match the most suitable documentation format for each specific consultation.
Examples of consult note types
MBSPro offers a versatile approach to note-taking, accommodating various documentation formats such as SOAP, Chief Complaint, and Multiple Presenting Complaints.
During the note generation process, MBSPro presents you with a range of note types to choose from, enabling you to customize your documentation approach according to your specific requirements and preferences.
What is the SOAP Format?
The SOAP format is a structured approach to documenting patient encounters, ensuring clarity and completeness in medical notes. SOAP stands for Subjective, Objective, Assessment, and Plan.
Subjective: captures information shared by the patient, including their chief complaint, history of present illness, past medical history, current medications, and social and family history. The
Objective: records findings observed during the patient encounter, such as physical examination results, vital signs like blood pressure and heart rate, laboratory results, and imaging findings.
Assessment: synthesises the Subjective and Objective information to arrive at a diagnosis or clinical impression, integrating the patient’s symptoms and observed signs into a cohesive
Plan:
details the next steps, which may include additional testing or labs, prescriptions or treatment recommendations, referrals to specialists or other clinicians, and any follow-up instructions.
SOAP example
Patient presenting 3 day history of cough and fever likely viral URTI
Plan - symptomatic management, review 1 week, increase use of Ventolin
History:
- Patient presents with a 3-day history of cough and fever.
- worsened overnight
- starting getting ear pain, runny nose and sore throat
- Associated symptoms include shortness of breath and malaise. Denies chest pain or hemoptysis.
- No recent travel or known exposure to infectious diseases.
- cough is productive
- coryzal symptoms present
- no red flags - non smoker
- PMHx: Asthma, seasonal allergies.
- Current medications: Salbutamol inhaler, loratadine.
- Social history: Has been in contact with some sick contacts, living at home with partner who smokes
- family history of atopy and asthma
- uptodate with flu shot but needs covid vaccine
Examination:
- Temp: 38.2°C, HR: 88 bpm, BP: 120/80 mmHg.
- Examination findings:
- heart sounds x 2
- Bilateral wheezes on auscultation, no crepitations.
- Mild pharyngeal erythema.
- ears erythematous both sides
Assessment & Plan:
1. Acute Bronchitis
- Likely viral etiology given the acute onset and associated symptoms.
- Recommend symptomatic management with increased fluid intake and rest. Consider over-the-counter cough suppressants if necessary.
- Follow-up in 1 week if symptoms persist or worsen.
2. Asthma Management
- Asthma symptoms may be exacerbated by current upper respiratory infection.
- Continue use of salbutamol inhaler as needed. Review inhaler technique and consider increasing dose if no improvement.
- Schedule follow-up to reassess asthma control.
What is the Chief Complaint Format?
The Chief Complaint format structures patient encounters around their main reason for visiting. It includes:
- Presenting Problem: The primary issue bringing the patient in
- History of Presenting Problem: Background details like symptom duration and specifics
- Examination: Objective findings related to the presenting problem
- Plan: Next steps, which may include tests, treatments, or referrals
Chief example
Consult Summary
Patient presenting with management of diabetes and stable hypertension for repeat bloods, flu symptoms likely asthma exacerbation for swabs, Depression and PTSD with insomnia increasing pristiq to 150mg nocte, prevenative health check recommending to up date FOBT
Problem List:
1. Diabetes mangement
2. Flu symptoms
3.Mental health
1. Diabetes management
- 3 monthly diabetes check
- Patient reports stable blood sugar levels, no recent episodes of hypoglycemia
- recent hba1c 6.9, LDL 1.4, egfr 87
- started on 2.5mg ramipril last review for high bp
- BP stable at 135/86 today
- no dizziness, chest pain, low bsl
- Compliance with medication has been good
- No changes in diet or physical activity - enourged to increase exercise
- Scheduled review with endocrinologist and podiatrist next week
2. Flu symptoms
- Onset of flu-like symptoms 3 days ago, including fever, cough, and fatigue
- some feelings of facial fullness
- No shortness of breath or chest pain
- denies haemoptysis, denies overly productive cough
- Recent exposure to a family member with similar symptoms
- Differentials - URTI vs asthma flare vs tonsilitis
3. Mental health
- Hx of PTSD since 2010, currently stable
- Experiencing low mood in context of month anniversary of mothers death
- Not engaging in usual hobbies as much as before
- Reviewed by Dr Kennedy recently, report not yet received
- Dr Kennedy opinion - no PTSD, consider increasing antidepressants if required, concerned re appetite increase with mirtazapine
- Discussed Saxenda, patient previously reluctant due to cost and stimulant effects
- Currently on: Mirtazapine 30mg, Pristiq 100mg
- Has not seen usual psychologist for tome time
Past Medical History:
- Asthma usually well controlled
- High blood pressure on ramipril
- Seasonal allergies controlled with dymista
Medications:
- Salbutamol
- Loratadine
- Ramipril
- Dysmista prn
- Metformin
- Empagliflozin
- Atorvastatin
- Mirtapazine
- Pristiq
Allergies
- Augmentin
Family History
- Mother with asthma and copd who was smoker
- Father with heart disease
- Brother with severe hayfever
Social History
- Smoker 20 cigs per day for last 20 years (20 pack year history)
- Lives at home with wife who is also smoker
- Some sick contacts recently at work
Preventative history
- Up to date with mammogram, eye test, cervical screening
- Repeat bowel screening required due to previous inadequate sample
- Vaccines discussed: requires prevenar, covid and shingles vaccine
Examination:
- Temp: 38.2°C, HR: 88 bpm, BP: 145/80 mmHg
- Heart sounds x 2
- Bilateral mildwheezes on auscultation, no crepitations.
- Ears erythematous both sides
- Throat - pharynx mildy erythematous, tonsils grade 2/4, nil exudate
Plan:
- Repeat diabetes bloods in 3 months
- Schedule endocrinology and podiatry review
- Increase Pristiq to 150mg and consider psychology review
- Safety netted r.e URTI symptoms - rest and reassurance
- Given pathology form for repeat FOBT
- prevenar and covid vaccine today, scheduled for shingles vaccine
What is the Multiple Presenting Problems Format?
The Multiple Presenting Problems format is designed for healthcare providers who often deal with patients having several issues. It maintains a structure similar to the Chief Complaint format but organizes information to address each concern individually.
Multiple problems example
Consult Summary
Patient presenting with management of hypertension which is stable, diabetes check up for repeat bloods, flu symptoms likely asthma exacerbation for swabs, Depression and PTSD with insomnia increasing pristiq to 150mg nocte, prevenative health check recommending to update FOBT
Problem List:
1. Hypertension management
2. Annual diabetes check-up
3. Flu symptoms
4.mental health
5.preventative health
1. Hypertension management
- Follow-up for hypertension
- started on 2.5mg ramipril last review
- Patient reports occasional headaches, no dizziness or chest pain
- headaches improving
- Compliance with medication has been good
- BP stable at 135/86 today
2. Annual diabetes check-up
- Routine annual check-up for Type 2 Diabetes
- Patient reports stable blood sugar levels, no recent episodes of hypoglycemia
- recent hba1c 6.9, LDL 1.4, egfr 87
- current medications are metformin 1g bd, empagliflozin 10mg od, atorvastatin 80mg od, ramipril 2.5mg
- No changes in diet or physical activity
- has reviewed with optomotrist last week - reported no issues wiht eyes
- schedued review with endocrinologist next week
3. Flu symptoms
- Onset of flu-like symptoms 3 days ago, including fever, cough, and fatigue
- some feelings of facial fullness
- No shortness of breath or chest pain
- denies haemoptysis, denies overly productive cough
- Recent exposure to a family member with similar symptoms
- nil tachpynoea, nil tachycardia, oxygen saturations 98% on room air, afebrile
- chest clear, good air entry, nil wheeze, nil crackles,
- ears - nil erythma, otherwise clear
- throat - pharynx mildy erythematous, tonsils grade 2/4, nil exudate
4. Mental health
- Hx of PTSD since 2010, currently stable
- Experiencing low mood in context of month anniversary of mothers death
- Not engaging in usual hobbies as much as before
- Reviewed by Dr Kennedy recently, report not yet received
- Dr Kennedy opinion - no PTSD, consider increasing antidepressants if required, concerned re appetite increase with mirtazapine
- Discussed Saxenda, patient previously reluctant due to cost and stimulant effects
- Currently on: Mirtazapine 30mg, Pristiq 100mg
5. Preventative check
- Up to date with: Mammogram, Eye test, Cervical screening, Bowel Cancer Screening
- Repeat required due to previous inadequate sample
- Vaccines discussed
- Needs preventative, covid and shingles vaccine
Plan:
- Order HbA1c test in 3 months
- Schedule foot exams with podiatrist
- Review results in 1 week along with review of URTIsymptoms if needed
- Encouraged to maintain 30 minutes of exercise per day
- Continue current antihypertensive medication
- Schedule blood pressure monitoring at home
- Increase Pristiq to 150mg and re-refer back to psychologist
- Review mental health care plan at next review
- Given pathology form for FOBT
- prevenar and covid vaccine today, scheduled for shingles vaccine