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Assessment drafting

Draft the assessment from the patient's records and edit it

Choose the document type and audience, add any instructions and start the draft. It streams into the editor with history, findings, assessment, differential diagnosis and plan, and you change whatever needs changing.

A drafted clinical assessment for exertional chest pain with history, findings, assessment, differential diagnosis and plan

Set up the draft the way you write

Pick the settings before you draft. Save them as a template when you want the same structure every time.

  • Document type and purpose

    Choose a clinical assessment and say what it is for, like a first cardiology review.

  • Audience, tone and length

    Write for a colleague, a ward team or the patient, at the length the reader needs.

  • Your own instructions

    Add free-text instructions, such as listing differentials in order of likelihood with the findings for each.

The settings for drafting a document from the patient's sources: document type, audience, length and instructions

Built in

Keep the doctor in charge of the document

The draft is a starting point. You edit it, and you decide what it says.

  • Edit in a rich-text editor

    Edit headings, lists and tables directly. The editor saves your changes as you type.

  • Draft from this patient's sources

    We draft from the documents and notes in this workspace, not from another patient's record.

  • Save templates

    Save a structure your department agreed on and draft from it every time.

Outcomes

What you gain when you start from a draft

  • You start from a structure

    You get history, findings, assessment, differential and plan laid out before you write a word.

  • You spend your time on the reasoning

    Spend the visit on what the findings mean instead of retyping what the referral said.

  • You keep assessments consistent across the team

    Share a template and every assessment in the department gets the same sections in the same order.

Comparison

Start the assessment from a draft instead of a blank page

TopicBeforeWith the register
Starting pointA blank page and a stack of lettersA draft built from the workspace sources
StructureWhatever the author rememberedThe sections your template sets
EditingCopying and pasting between documentsOne rich-text editor with autosave
ResponsibilityThe doctor'sYou stay responsible for the document

Questions

Frequently asked questions

Does it make the diagnosis?

No. The draft includes a differential diagnosis section for you to check, reorder or rewrite. You decide the working diagnosis and the plan.

Can I change the structure?

Yes. Set the document type, purpose, audience, tone, length and instructions for each draft, or save them as a template.

Does anything go into the patient record automatically?

No. Nothing leaves the workspace until you export it as PDF or Word and file it yourself.