Custom Note Workshop

Created by Amy Rogge OTD OTRL, Modified on Tue, Sep 15 at 9:54 AM by Amy Rogge OTD OTRL

What Your AI Assistant Can Do:

  • Shift formatting: Switch sections between dense paragraphs, quick bullet points, or specific outlines.

  • Control verbosity: Make specific sections highly detailed or ultra-concise.

  • Adapt to clinical specialties: Tune sections to listen for and prioritize specialty-specific data (e.g., pelvic health, pediatric milestones, vestibular metrics).

  • Rearrange items within a section: Change the sequence of fields inside a specific part of your note (e.g., putting 'Range of Motion' before 'Strength' inside the Objective section).

  • Remove unused fields: Clean up your template by deleting sections that don't apply to your specific setting.


What the AI Cannot Do:

  • Move fields between main sections: Think of your template like a filing cabinet. You can rearrange the files inside the "Objective" drawer, but you cannot move a file from the "Plan" drawer into the "Assessment" drawer (e.g., you cannot move "Goals" into the "Subjective" section).

  • Create brand-new fields: You cannot add entirely new data fields that aren't already part of the master template library.


Quick Tips: Phrasing Your Requests

What You Want to Change

❌ Avoid Requesting It This Way...

✅ Request It This Way Instead!

Using Examples (No PHI)

Pasting a real past note that contains a real patient's name, date of birth, or identifiable history.

"I want my assessments to match this format. Here is a mock example using fake data: 'Patient John Doe is a 65yo male presenting with... [insert fake text here]'"

Paragraphs vs. Bullets

"Make the subjective section look cleaner."

"Change the Subjective section to output as a bulleted list rather than a paragraph."

Length & Verbosity

"Make my assessments shorter."

"Keep the Assessment highly concise—limit it to 2–3 sentences highlighting medical necessity."

Niche Specialty: Vestibular

"Make this template work for my dizziness patients."

"Modify the Objective section instructions to specifically prioritize nystagmus tracking, VOR testing, and balance metrics."

Niche Specialty: Pediatrics

"Change this layout for kids."

"Modify the Objective and Assessment instructions to focus on age-appropriate developmental milestones."

Specific Clinical Formats

"Use a good formatting style for my goals."

"Update the Plan section to always format SMART goals using this structure: 'Patient will [action] given [assistance level] in order to [functional task] within [timeline].' "

Removing Clutter

"Stop showing me stuff I don't use."

"Please remove the 'Pediatric Milestones' field from my adult outpatient template."



Best Practices for Clinical Tailoring

The Secret Weapon: "Modify the Instructions"

Since you can't move fields between different main sections, the best way to get a specialized note is to tell the AI how to look for and write data within its existing section.

  • Provide a "Mock Example" (Strictly No PHI): The absolute fastest way to get exactly what you want is to show the AI a perfect example of your preferred style. Just write a quick snippet using a completely fake patient identity (e.g., Jane Doe) or use brackets as placeholders.

    • Example to paste into chat: "I want my Goals section to always look exactly like this format: 'Patient will [perform functional task] independently with [assistive device] within [timeline] in order to safely return to [specific community activity].'"

  • Specify the "Lens" for the AI: If you treat a niche population, tell the assistant what details are most important to you. (e.g., "For the Objective section, always format lymphedema tracking into a clear list of circumferential girth measurements.")

  • Give it a Word Count or Sentence Limit: If the AI is being too wordy, give it hard boundaries. Try: "Keep the History of Present Illness to a maximum of 4 bullet points."

  • Be Specific If Reordering: On the rare occasion you want to rearrange items inside a drawer, tell the AI exactly where they belong. (e.g., "Inside the Objective section, move 'Fine Motor Skills' above 'Gross Motor Skills'.")

  • Test with Real Clinical Data: The AI won't automatically show you a sample note after a change. Once you finish tweaking your template, test it by saying: "Can you generate a preview of a note using my last session data so I can see how it looks?"




? Troubleshooting: When the Preview Isn't Quite Right

Sometimes the first draft of your custom template might miss the mark. If your preview note doesn't look exactly how you envisioned, use these quick fixes to coach the AI:

  • Problem: "The AI included information, but put it in the wrong section."

    • Fix: Remind the AI of its boundaries. Say: "In the template instructions, make sure that any mentions of assistive devices go into the Objective section, not the Subjective section."

  • Problem: "It's still writing way too much prose/paragraphs."

    • Fix: Give it a strict numerical constraint. Say: "Modify the Assessment description to strictly forbid paragraphs. Force it to write exactly 3 bullet points: 1 for clinical summary, 1 for medical necessity, and 1 for rehab potential."

  • Problem: "It completely missed a niche clinical detail I mentioned in my session."

    • Fix: Tell the AI to prioritize that data point in the underlying instructions. Say: "Update the Objective section instructions so that if I mention 'sacral alignment' or 'palpation findings', they are always highlighted in bold at the top of that section."

  • Problem: "I want to undo the last change I made."

    • Fix: Just ask! Say: "Actually, I don't like how those bullet points look. Please revert the Subjective section back to paragraph format."

    • Revert to previous version: Locate the clock icon in the upper right corner of the note you’re personalizing. Select the version to which you’d like to revert by selecting from the list



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