AI Note Assist: Office Visit

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Updated: 05/20/2025 | Views: 367

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 scribed documentation with intelligent prompts for diagnosis codes—allowing providers to focus less on admin and more on patient care. AI Note Assist is available for the following note types: SOAP, Therapist Initial Visit, Therapist Progress, Psych Initial Visit, and Psych Progress.

Learn how to start AI Note Assist for in-person office visits - which 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 finalize the note.

Review AI Note Assist: Telehealth Visit to learn how to start AI Note Assist for telehealth visits.

Notes:

Chrome is the preferred browser for optimal use for AI Note Assist.
Available for Clinical subscribers at a usage-based fee per note. For the cost of using AI Note Assist, see the AI Note Generation Fee section of the Pricing Policy. Charges incurred are added to your next monthly invoice.
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.

Access AI Note Assist AI Note Assist can be created from three different locations: the patient's appointment on the Dashboard, the patient's Facesheet, and the Notes tab. It is recommended to create the note from the patient appointment to auto-populate appointment details. Important Note: Do not create a clinical note from the appointment when 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 option to start the AI Note Assist from the appointment card will no longer be available. 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. Click on the patient's appointment to view the appointment card. Click AI Note Assist. The note opens. Note: If a clinical note for this appointment is in progress, the AI Note Assist option will be unavailable. If this is the first time the provider is using AI Note Assist, the Premium Service Acknowledgement pop-up window opens. Review the note and click Continue to agree to the terms.
Start Recording Before using AI-powered scribe tools, review applicable laws and regulations in your practice’s jurisdiction regarding electronic recordings, AI scribes, and informed consent. Some jurisdictions require verbal or written consent prior to any form of ambient documentation. Check your state board or consult legal counsel for guidance. By default, the date and time of the appointment displays. If the note was not created from an appointment, the date and time the note was started displays. To change the date and/or time, click to select a different date and/or time for the visit. If applicable, click the Assigned To drop-down arrow to select a provider or clinical assistant to assign the note to. Click the Note Type drop-down arrow and select Psych Initial Visit, Psych Progress, SOAP, Therapist Initial Visit, or Therapist Progress. Click Start Recording. The Session Recording pop-up window opens. Note: Select a note type to enable this option. If applicable, click Allow while visiting the site to activate the microphone for the current and future AI Note Assist sessions.
The patient visit is recorded for up to 2 hours. Note: To be HIPAA compliant, Tebra does not store session recordings. To temporarily stop the session from being recorded, click the pause icon. The session stops recording. To resume recording, click the mic icon. To restart the AI Note Assist and disregard the recording for the current session, click the pause icon. Additional options displays. Click the restart icon. Then, click Restart Recording to confirm. Chart Details: To review the patient's documented Medication, Problem, History, Vitals, Allergies, Lab and Studies, or Immunization click the sections to expand. Click the end recording icon to stop recording and start generating the clinical note. The AutoGen Note pop-up window opens. Note: Do not refresh or navigate away from the page while the note is generated. This may result in the loss of data and the AI note will not generate. Once the clinical note is generated, the note opens. The provider can review, edit applicable sections, and add note sections (to populate documented or new structured data) to finalize the note.