Learn about the changing scribe output
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
2. View Scribe Options
a. 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.
3. 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, preventative health check recommending to up date FOBT
Problem List:
1. Diabetes management
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 - encouraged 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 mildly 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 optometrist last week - reported no issues with eyes
scheduled 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