Emergency medicine AI documentation best practices for physicians
The Emergency Medicine AI model generates clinical documentation from what you explicitly say while recording. To ensure optimal emergency department (ED) output from DAX or Dragon Copilot, speak your medical decision-making (MDM) aloud as a conversational clinical narrative during recording: your concerns, what you did, what you found, how you interpreted it, and why you chose the disposition.
Note
This guidance assumes that the Primary specialty setting in your DAX or Dragon Copilot Profile is set to “Emergency Medicine”.
Recording best practices
Clear, comprehensive recordings help ensure the best possible documentation.
In your first recording(s) capture critical contextual information, including:
The chief complaint, key past medical history, and the historian providing the details.
Your observed findings not already verbalized, and any risk modifiers or limitations.
Add follow-up recordings at inflection points (results returned, reassessment and response to therapy, consults, and disposition changes).
Verbalize timestamps as necessary (for example, “At 14:10…”). Times are not inferred.
Each recording contributes to the transcript used to generate your clinical documents.
Record clinical information inside or outside the exam room, whether it’s an ambient conversation or a private monologue. (Stop and restart recording as necessary to avoid capturing extraneous conversations.)
While recording, ensure proper device placement so the microphone on the device is not obstructed (e.g., in your breast pocket upside down) to ensure clear recording.
What to include in your recordings
Follow these guidelines to ensure the information you want to include appears correctly in your clinical documents.
Assessment and differential: Name the diagnoses you are considering and the key risk and context modifiers that raise or lower concern (for example, immunocompromise, anticoagulation, recent surgery, or prior similar episodes), including who provided the history and any limitations.
MDM chain (medical necessity): State the logic in sequence (concern or diagnosis → orders and therapy → results → your interpretation → next step), including chronic conditions, social determinants of health (SDOH) that changed care, and any risk tools used (and how they influenced the disposition).
Orders: Verbally include the details of the medications given or ordered, and each lab or imaging study ordered if you want them included in your documents.
Interpretation and records: If you independently interpret a test, say “I independently interpreted …” and then state the finding. Also state which internal or external records you reviewed, and the specific relevant information obtained.
Disposition: Once decided, clearly state whether the patient is discharged, admitted, placed in observation, or transferred. Include follow-up and return precautions, and document shared decision-making (risks, benefits, alternatives, and patient preferences) when applicable.
Critical care: Critical care time is not inferred. Verbalize the total minutes and use compliant phrasing when applicable (for example, excluding separately billable procedure and documentation time).