Documentation Preferences Guide for palmER AI Suite

What Are Documentation Preferences?

Documentation Preferences (also known as custom instructions) allow you to personalize how palmER AI generates your documentation. Think of them as your personal preferences that guide the AI to write notes in your preferred style, include specific elements important to your practice, and align with your institutional requirements.

Why Use Documentation Preferences?

• Match your preferred documentation style and terminology
• Include elements you always want documented
• Use your preferred medical terminology
• Emphasize specific clinical decision tools
• Customize documentation length and detail level

Documentation Preferences vs Follow-up Prompts

✅ Use Documentation Preferences For:

• Style preferences: "Use first-person active voice"
• Content emphasis: "Always include specific follow-up timelines"
• Terminology: "Use 'denies' instead of 'reports no'"
• Clinical tools: "Include HEART score for chest pain patients"
• Detail level: "Keep documentation short and concise for straightforward cases"

🔄 Use Follow-up Prompts For:

• Major format changes: Converting narrative to bullet points
• Specific templates: Structured formats with headers and sections
• Complete reorganization: Changing from prose to lists or tables
• One-time modifications: "Reformat this as bullet points under these headings"

Example Follow-up Prompt: After generating an MDM, you can ask: "Please reformat this MDM using bullet points with these sections: Problems Addressed, Data Reviewed, Assessment, Plan, Risk Assessment"

Getting Started

Accessing Documentation Preferences

1. Navigate to Settings in palmER AI Suite
2. Find Documentation Preferences section
3. Choose the assistant you want to customize:
   • HPI Assistant
   • Physical Exam Assistant
   • MDM Assistant

Setting Up Your First Documentation Preferences

Start Simple: Begin with 1-2 basic preferences, test them, then add more.

Example Starting Point:

Use first-person active voice throughout.
Always include specific follow-up timelines.

Writing Effective Documentation Preferences

What Works in Documentation Preferences:

• Style preferences: "Use first-person active voice" or "Keep documentation concise"
• Terminology preferences: "Use 'denies' instead of 'reports no'"
• Institution-specific requirements: "Always mention our Fulton County General chest pain protocol"
• Clinical decision tools: "Include Ottawa ankle rules for all ankle injuries"
• Documentation emphasis: "Always document patient understanding confirmation"

What Doesn't Work in Documentation Preferences:

• ❌ "Format as bullet points with these headers..."
• ❌ "Use this specific template structure..."
• ❌ "Organize into numbered sections..."
• ❌ Complete format overhauls

Best Practices

1. Be Specific: Instead of "better documentation," say "include specific vital sign parameters in risk assessment"

2. Test Incrementally: Add one instruction, test it on a few cases, then add more

3. Use Examples: "Include medication compliance status for chronic conditions like diabetes and hypertension"

4. Think Workflow: Consider what content you find yourself adding manually to AI-generated notes

5. Remember the Boundary: Documentation preferences modify content and style within the existing format

When to Use Follow-up Prompts

Scenario 1: Structured Templates

If you want a specific template format:

1. First: Generate documentation with your preferences for content requirements
2. Then: Use follow-up prompt: "Please reformat this using my template:..."

Scenario 2: Bullet Point Lists

If you prefer bullet points:

1. First: Generate narrative documentation
2. Then: Ask: "Convert this to bullet points..."

Scenario 3: Institution-Specific Formats

If your institution requires specific formatting:

1. Documentation Preferences: Include content requirements
2. Follow-up Prompt: Request specific formatting structure

Common Use Cases

Personal Documentation Style

Always lead with the most critical differential diagnoses.
Use concise, direct language.
Include specific follow-up timelines for all recommendations (within 24-48 hours, etc.)
Emphasize quality metric compliance (door-to-needle times, etc.)

Clinical Decision Tool Preferences

Always include HEART score for chest pain patients.
Always include CHADS2-VASc score for atrial fibrillation patients
Include CURB-65 for all pneumonia cases.

Billing and Complexity Documentation

Always explicitly state MDM complexity level and justification.
Emphasize data review elements that support complexity levels.
Document independent interpretation when performed.

Assistant-Specific Tips

HPI Assistant

• Documentation Preferences Focus: Terminology preferences, information you always want included
• Example: "Always include family history of cardiac disease for chest pain patients"
• Follow-up prompt for: Converting to bullet points or specific institutional HPI templates

Physical Exam Assistant

• Documentation Preferences Focus: Preferred abbreviations, level of detail, specific exam components
• Example: "Use 'alert and oriented x3' instead of 'AAOx3'"
• Follow-up prompt for: Reorganizing into different system groupings or bullet format

MDM Assistant

• Documentation Preferences Focus: Clinical documentation style, content emphasis, risk stratification preferences
• Example: "Emphasize shared decision-making process details for complex cases"
• Follow-up prompt for: Converting to structured templates, bullet points, or specific institutional formats

Testing Your Documentation Preferences

Step-by-Step Testing Process

1. Save your preferences in the settings
2. Test with a simple case you're familiar with
3. Review the output - does it match your content preferences?
4. If format changes needed: Use a follow-up prompt
5. Refine your preferences based on content needs
6. Test with different case types to ensure consistency

What to Look For

• ✅ Your preferred terminology is used
• ✅ Required content elements are included
• ✅ Documentation style matches your preference
• ✅ No inappropriate content was added
• ✅ Core medical standards are maintained

Troubleshooting

"My formatting preferences aren't working"

• Solution: Use a follow-up prompt for format changes instead of documentation preferences
• Example: Generate the note first, then ask "Please format this as bullet points"

"Output structure doesn't match my template"

• Solution: Documentation preferences handle content; follow-up prompts handle structure
• Workflow: Documentation preferences → Generate → Follow-up prompt for formatting

"My preferences aren't working"

• Check specificity: Vague instructions may not be followed consistently
• Test individually: Try each preference separately to identify issues
• Verify scope: Ensure you're requesting content changes, not format changes

"Output is too long/short"

• Add length guidance: "Keep HPI to 4-5 sentences for straightforward cases"
• Specify detail level: "Use detailed documentation for complex cases only"

Sample Documentation Preferences by Role

Emergency Department

Use first-person active voice throughout.
Always include HEART score for chest pain regardless of risk level.
Emphasize social determinants of health when relevant.
Include specific follow-up timelines (24-48 hours, etc.).
Always document patient understanding confirmation for high-risk discharges.

Urgent Care

Keep documentation concise for straightforward cases.
Include work/school restrictions when applicable.
Use 'advised to follow up with primary care within X days' format.

Academia

Include teaching points when relevant to case complexity.
Document resident involvement when applicable.
Emphasize evidence-based decision making rationale.

Quick Start Checklist

• Choose one assistant to start with (recommend MDM)
• Write 2-3 simple, specific content preferences (not formatting)
• Test with a case you know well
• If format changes needed, use follow-up prompts
• Refine your preferences based on content output
• Gradually add more content preferences
• Test across different case types
• Save backup of working preferences

Pro Tips

Efficient Workflow:

1. Set up documentation preferences for your content requirements
2. Generate documentation
3. Use follow-up prompts for any formatting needs
4. Save successful follow-up prompts for future use

Template Strategy:

• Create documentation preferences for what you always want included
• Develop standard follow-up prompts for your preferred formats
• This gives you both consistent content AND flexible formatting

Remember: Documentation preferences enhance the AI's content generation - follow-up prompts handle structural changes. Together, they give you complete control over your documentation.