How to Document a Wound Care Visit with Ambient AI
tutorial
A step-by-step walkthrough for wound clinicians who want to capture a complete SOAP note hands-free during the visit — measurements, images, and codes included.
Documenting a wound visit shouldn't mean another hour after clinic. This walkthrough shows how to run a full encounter with ambient AI scribing so the note is mostly written by the time you wash your hands.
Step 1 — Open the encounter and pull the longitudinal context
Start the visit from the patient chart. The platform surfaces active wounds, prior measurements, comorbidities, and the last care plan so you're not flipping tabs to remember where things stood.
Step 2 — Capture the wound image
Point and capture at the bedside. The imaging agent calibrates dimensions, segments tissue types (granulation, slough, eschar), and flags peri-wound findings for your confirmation.
Step 3 — Let ambient scribing transcribe the conversation
Talk to the patient normally. The scribe captures symptoms, history, and your verbal exam findings, then structures them into the subjective and objective sections.
Step 4 — Review the drafted SOAP note
The assessor agent ties findings to the patient's profile. You see a draft assessment and plan grounded in the chart — not generic boilerplate. Edit inline where needed.
Step 5 — Approve orders, referrals, and codes
Four order-writers propose medications, labs, imaging, and referrals. At wrap-up, E/M and CPT codes are tied to the note. You sign off; nothing enters the legal record until you do.
Step 6 — Send the take-home summary
The visit is translated into plain-language patient education so caregivers know exactly what to do next.