AI Note Assist: Clinical Assistant Workflow

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Updated: 05/20/2025 | Views: 290

Tebra’s AI Note Assist revolutionizes clinical documentation by streamlining the note-taking process for in-person and Telehealth visits (Telehealth subscribers). Powered by advanced AI with ambient listening, it offers automated scribe documentation with intelligent prompts for diagnosis codes—allowing providers to focus less on admin and more on patient care.

AI Note Assist allows providers to quickly start their notes and capture key clinical information. After the AI generates the note, the provider will need to add structured data, such as vitals and medications. To streamline the provider's workflow, Tebra recommends clinical assistants enter structured data into the patient's Facesheet during the visit, so most information is already populated when the provider adds the applicable sections after the AI note is generated and finalizes the note.

Note: Do not create a clinical note from the appointment when the provider is using AI Note Assist for the patient visit. If a clinical note is created for the appointment, it will result in duplicate notes for the same visit and the provider will not have the option to start the AI Note Assist from the appointment card.

Access Patient Facesheet

Hover over the Platform icon and click on Dashboard. The Dashboard opens.
Click the In Office tab. All patients with an in-office status display.
- For telehealth appointments, join the room to get clinical information before the provider joins, if applicable to the practice's workflow.
Click on the patient's name. The patient's Facesheet page opens.
Important Note: Do not create a clinical note from the appointment. The option for AI Note Assist will not display for the provider on the appointment card if a clinical note is created.

Document Clinical Data

To streamline the provider's AI Note Assist workflow, complete the following sections for the current patient visit.

Document patient clinical structured data for the provider to include in the clinical note after the AI note is generated.
- History: Click to review the patient's history and document the patient history, as applicable.
- Medications: Click to review and verify the patient's active medications. If applicable, add medications to the med list or discontinue medications.
  Tip: If available, queue up medication orders to prepare prescriptions for provider approval.
- Immunizations: Click to review the patient's immunizations and document a vaccine or administer a vaccine, as applicable.
- Allergies: Click to review the patient's allergies and add new allergies or mark an allergy as inactive, as applicable.
- Vitals: Click to review the patient's prior vitals. Then, document the patient's vitals for the current visit.
Once completed, the provider can start the AI Note Assist for an in-person office visit or a telehealth visit (Telehealth subscribers) and add the applicable sections (vitals, medications, etc.) after the AI note is generated.