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Clinical note templates best practice

๐Ÿ‡ฆ๐Ÿ‡บ๐Ÿ‡จ๐Ÿ‡ฆ๐Ÿ‡ฌ๐Ÿ‡ง๐Ÿ‡ฎ๐Ÿ‡ช AU, CA, UK, ROI - How to structure your note templates to get the best results out of clinical AI notes.

Amber Morris avatar
Written by Amber Morris
Updated over a month ago

Use the following formatting rules when creating AI note templates to get consistent, structured, and high-quality note output.

1. Use clear section headings

Structure your template into clear, labelled sections (e.g. Chief Complaint, Medical History, Treatment Plan). This improves consistency in how the AI formats and returns notes.
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Example:

Chief Complaint: [Chief complaint] 
Medical History: [Relevant history]
Treatment Plan: [Treatment 1] / [Treatment 2]

2. Use brackets to define input and options

When providing multiple options or expected input, use square brackets. This helps the AI understand the field and the type of information it should return.
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Example:

Smoking: [Never / Ex-smoker / Daily / Occasional]

3. Use Bullet Points or Numbering for Lists

To create structured lists, use bullet points or numbered formats in your template.
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Example bullets:

Plan: 
- [Topical fluoride]
- [Oral hygiene advice]

Numbered steps:

Post-Treatment Instructions: 
1. [Rinse mouth]
2. [Avoid eating for 30 minutes]

4. Write reusable phrases as fixed text

If a line should always appear as-is, write it into the template exactly how you want it.

Example:

Patient consent obtained.

This ensures the AI includes the text unchanged.


Optimised clinical AI notes outcomes

Below you can see an example side by side of the initial system 'AI Adult Exam' template (left) before generating a summary, and the outcome of the generated summary (right) after dictation. You can clearly see it has kept the structure, header and fixed text. Whilst choosing one option where prompted and filling in bullet points as needed.

Screenshot showing one of the default ai system templates that are optimised to work with clinical ai notes.screenshot showing the generated summary of the same adult exam system template with the same layout and headers followed through.

๐Ÿ’ก Top Tip - Start with a System Template! Use existing system templates (like AI Adult Exam) as a starting point. These are designed specifically for AI use and already include best practice formatting.
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โ€‹Want to further customise these templates? Head over to our dedicated article on cloning and editing a clinical note template here ๐Ÿ‘ˆ


Why this matters?

When your template has clear structure and formatting hints, the AI knows how to follow your lead โ€” and youโ€™ll get cleaner, more predictable note outputs every time. If your template is vague or empty, the AI will do its best to fill in the blanksโ€ฆ but results will vary.


What if you donโ€™t follow these steps?

Templates with unclear or missing structure may:

  • Return inconsistent or restructured notes.

  • Vary in formatting between uses.

  • Make dictation harder by requiring more manual input after dictation.

Use these best practice guidelines to save time and improve accuracy across your clinical notes.

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