When generating your notes, Lyrebird offers various note types for you to choose from.
Why might I change my note type?
Altering your note type changes how Lyrebird writes your notes. Technically speaking, it will change the instructions you are giving Lyrebird.
How can I change my note type?
You can change your default note type by heading to Customise → Notes → Note Template.
You can also alter your note type before or during your consultation.
Let's take a look at the three different note types:
What is the SOAP format?
SOAP notes follow a basic structure:
Subjective: This section provides context for the Assessment and Plan sections of the note. It might include the patients Chief Complaint, History of Present Illness, Medical History, Current Medications etc.
Objective: This section documents the objective findings from the patient encounter. This section will not include symptoms, but it will include signs.
For example:
A patient's "stomach pain" would be listed under:
Subjective heading: As a symptom, "stomach pain" would be listed
Objective heading: As an objective sign, "abdominal tenderness to palpatation" would be documented
Assessment: This section documents the synthesis of Subjective and Objective evidence to arrive at a diagnosis.
Plan: This section details the actions following the consult, this might be additional testing or referral to another clinician.
Let's look at an example:
What is the Chief Complaint format?
Chief Complaint follows a slightly different structure.
Presenting Problem: Documenting the patients main presenting problem.
History of presenting problem: Documenting the history of the patients problem, how long they've had symptoms, what symptoms they've had etc.
Examination: This section documents the objective findings from the patient encounter.
Plan: This section details the actions following the consult, this might be additional testing or referral to another clinician.
Let's look at an example:
What is Multiple Presenting Problems format?
Multiple presenting problems is the perfect note structure if you're a clinician who often see's patients with multiple concerns. It follows a similar structure to Chief Complaint, but breaks it down into multiple problems.
Let's look at an example:
Why can I only see two note types?
For most fields of practice, you'll see three note types. If you cannot see Multiple Presenting Problems and you think it would suit your workflow, please contact us.