Write Discharge Notes with AI

How to Write Discharge Notes With AI

Healthcare professionals have to deal with a lot of paperwork, and discharge papers are just one kind that you might handle regularly. Unfortunately, many doctors waste more than half their time handling paperwork. Many physicians spend nearly twice as much time doing paperwork as seeing patients. Even in examination rooms, they still spend only half their time examining or talking to patients because most of the rest of their time is still filled with doing paperwork. Fortunately, AI technology is here, and you can use it to write discharge notes faster than ever before.

What Are Discharge Notes?

Whenever you discharge patients, you are going through a complicated process. One crucial aspect of this process is creating the documentation for discharge notes or the discharge summary. This clinical report happens at the end of a client’s stay or when their treatments are done, and it’s often a primary means of communication between the initial care team and any aftercare providers. Many jurisdictions consider a set of discharge notes to be a legal document, and any errors within it might hurt the care of the client. Also, delays in finishing discharge notes can heighten the risk of the client being readmitted.

Depending on your specific field, state, and medical setting, the specific data and information you need to include in your discharge notes can vary greatly, but certain information usually needs inclusion. Patient details include full name, date of birth, telephone number, address, sex at birth, current gender, ethnicity, and next of kin. Information about the client’s primary care physician should include the professional’s name, identifier, and contact details for their place of practice. The discharge notes should also cover the discharging consultant and department, the time/date of admission and discharge, and the discharge destination. Summarize the clinical details about the client’s symptoms, examination, and diagnosis, and then provide notes about any procedures or treatments done during admission. Referrals and follow-up care instructions are crucial for the client and aftercare teams. Also, include all medications that need to be taken.

Writing Discharge Notes With AI

The digital age has progressed far enough to see the advent of artificial intelligence technology. This isn’t the kind of sentient machines or thinking computers so common in science fiction — it’s machine learning, and it’s a powerful tool in many fields. Healthcare is no exception, and professionals can use AI in their facilities. One specific application is potentially using AI to write your discharge notes for clients. This helps you save time and labor while ensuring that your discharge summaries are accurate and comprehensive. This helps boost communication between healthcare professionals and makes the care transition smoother for clients.

Depending on the specific AI tools you are using, you might start using either a prompt or a template. These serve as the starting point for creating the documentation that you want. A specific prompt tells the AI to generate discharge notes that are comprehensive and understandable, and enough of these prompts can help you start generating your templates if there are none currently in the available directory. The essential information you might start a prompt or template with includes the patient’s name, diagnosis, age, and pertinent medical history. It would be best if you also commanded the AI to include several crucial components, including the condition of your client at the time of discharge, suggestions for aftercare, lifestyle modifications, and recommended or prescribed medications.

While AI can do a lot of work for you, it won’t do all of it. You need to summarize any client session in a few sessions by typing it in or using an available dictation feature. Make sure you cover treatment plan strategies, objectives, and goals. Note any ICD-10 diagnoses. While clients might not know what these codes are, aftercare professionals will. Your AI and clients can use these codes to look up information about the specific conditions diagnosed and associated with these codes. This is where AI can improve the accuracy and thoroughness of discharge notes that help all parties involved.

Ensure that your comprehensive notes are customized with your clinician information and medical practice logo so everyone knows where the discharge papers originated. Proper discharge planning is a requirement for many medical and healthcare facilities across the country. Proper documentation is crucial given how a population that is rising in average age is more likely to have chronic conditions that require management over time. Most AI tools allow you to download the document as a PDF file, which is a universal file type that anyone can open and use. This method helps clients access all of the information, but you should first proofread and edit as necessary.

The most prominent thing to look out for is any potential HIPAA violations. Be sure that all your client data is protected. Privacy violations not only jeopardize the safety of clients but also your career and the setting you work in. Whenever possible, anonymize client information in the AI prompt or template. Being mindful of security and privacy extends to any cloud servers your AI tool has access to or relies on.

Proofreading and editing AI content is also crucial. While machine learning technology often presents accurate, coherent text, it’s not human, and it’s still developing. This is where your own education and clinical experience come into play. Verify that anything the client reads is organized, thorough, and understandable. Look for two things. First, see if there are any errors or misrepresentations in the information present. Second, add what you think should be included.

Discharge Notes Are Time-Consuming

Over 30% of doctors report spending more than 20 hours a week on administrative tasks, and that’s not just physical paperwork. Electronic health records systems also take up a lot of time, and that was information reported from over 20,000 medical professionals. The more time healthcare professionals spend writing discharge notes, the less time you spend with your clients. It also slows down discharges for clients and all operations you’re a part of. Communication with aftercare teams is also delayed.

How AI Can Help

A recent study suggested that AI tools can help professionals across many industries boost their productivity by an average of 14%. Healthcare professionals sometimes overlook discharge notes since the client has been cared for and is on their way out. Creating high-caliber discharge notes involves containing all information required by the client and aftercare providers and as dictated by laws and regulations. Unfortunately, these documents are frequently a lower priority or even dropped into the lap of junior professionals already under a heavy work burden.

Client Comprehension

Your clients might have trouble following the discharge notes that they are given. Medical terminology is often unfamiliar. AI can help make discharge notes easier for clients to understand. Some AI tools have options you can use to target a specific reading level, and many American adults do best with content written for around eighth grade. 

While you should always go over care instructions with your clients verbally, AI-created discharge notes can help them remember what you tell them. Print a sheet out and hand it to them, or give them a digital copy via the patient portal or email. Listing out things in bullet points helps them follow their care instructions one step at a time and improves their odds of getting better.

Reduced Stress for You

Over half of primary physicians report feeling burned out right now, and many are either planning to or considering leaving the industry altogether. Workplace conditions and deadline pressures constantly stress out many healthcare professionals, but AI technology can help you automate certain tasks and streamline processes that you handle repeatedly. Anything that helps you juggle fewer tasks or get through them easier is going to reduce your stress load, and that leaves you more available to help clients out with their ailments.

Features Your AI Tool Should Have

Google is already using AI in a number of its own products and services, and employees within that company have certain features that they look for when choosing specific machine learning applications. Likewise, you should seek out certain benefits or features in any AI tool you choose to help you create discharge notes. This is no different than having a checklist of skills or requirements you want out of a potential human employee since you are looking for something to do work for you.

Deidentified PHI

The idea of deidentifying data is not exclusive to the medical field, but that’s what most people associate it with. Dynamic data masking is one way to break links between data and individual associations. This involves either the transformation or removal of personal identifiers when data might need to be shared with third parties. Client data needs to be in place for customized discharge notes. Still, data deidentification is crucial to protecting client privacy if data is used in broader studies or when anyone is analyzing a broader patient population for macro trends.

Access to ICD-10 Codes

AI tools with access to ICD-10 code databases can generate substantial information for aftercare teams and clients alike to learn about the specific diagnoses involved. This information matters greatly in terms of health insurance, too. Insurance providers know which specific treatments they are paying for, and clients might be better able to predict their copays. ICD-10 codes in discharge notes also promote higher efficiency rates and reimbursement to medical providers and locations. Having the right codes also means that accurate information is provided to clients and aftercare teams, and communication is vastly improved even when you might spend less time generating discharge notes. This can lead to beneficial developments in your relationships with other healthcare professionals and your clients.

Secure and Encrypted

You’re probably already familiar with the HIPAA Security Rule governing risk analysis regarding personal health information, be it analog or digital. HIPAA rules apply to any AI tools you use, servers where they store data, and any online connections used to transmit data. Fortunately, legitimate AI tools designed for creating discharge notes should already meet HIPAA rules regarding server storage and digital connections. Both technical and nontechnical safeguards can protect your client information, and you can create discharge notes freely.

AutoNotes Can Help

If you want an AI tool that you can use in writing discharge notes, then AutoNotes is something to consider. Speed up writing discharge notes, enjoy higher accuracy rates, and provide your clients with usable information. When it’s presented in a format they can easily understand, they’re more likely to follow through with their treatment and aftercare. In the best cases, readmission rates go down. Not only will AutoNotes make things better for you now, but you can also count on it to get better over time. We’re always listening and learning based on specific metrics and client feedback, and we use all this to improve AutoNotes continuously.

Say Goodbye to Manual Notes with AutoNotes