AWS HealthScribe Clinical Documentation file
AWS HealthScribe can use one of the following templates for the clinical note summary. The default is HISTORY_AND_PHYSICAL.
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HISTORY_AND_PHYSICAL: Provides summaries for key sections of the clinical documentation. Examples of sections include Chief Complaint, History of Present Illness, Review of Systems, Past Medical History, Assessment, and Plan.
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GIRPP: Provides summaries based on the patients progress toward goals. Examples of sections include Goal, Intervention, Response, Progress, and Plan.
To specify what template to use, do the following:
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For transcription jobs, specify the template to use in the
NoteTemplateof the ClinicalNoteGenerationSettings of theSettingsof your StartMedicalScribeJob API operation. For streaming, you specify the template to use in the
NoteTemplateof the ClinicalNoteGenerationSettings of thePostStreamAnalyticsSettingsof your MedicalScribeConfigurationEvent.
HISTORY_AND_PHYSICAL template sections
The HISTORY_AND_PHYSICAL insights template includes the following sections.
| Section | Description |
|---|---|
|
CHIEF COMPLAINT |
Brief description for the patient's reason for visiting the clinician. |
|
HISTORY OF PRESENT ILLNESS |
Notes that provide information on patient's illness, including reference to severity, onset, timing of symptoms, current treatments, and the affected areas. |
|
REVIEW OF SYSTEMS |
Patient-reported evaluation of symptoms across different body systems. |
|
PAST MEDICAL HISTORY |
Details a patient's previous medical conditions, surgeries, and treatments. |
|
ASSESSMENT |
Notes that provide information on clinician's assessment of patient's health. |
|
PLAN |
Notes that reference any medical treatments, lifestyle adjustments, and further appointments. |
|
PHYSICAL_EXAMINATION |
Documentation of clinician's findings from physical examination of patient's body systems and vital signs. |
|
PAST_FAMILY_HISTORY |
Information about health conditions that run in the patient's family. |
|
PAST_SOCIAL_HISTORY |
Details about patient's social life, habits, occupation, and environmental factors affecting health. |
|
DIAGNOSTIC_TESTING |
Results and interpretation of laboratory tests, imaging studies, and other diagnostic procedures. |
Each sentence present in the Summary includes EvidenceLinks that provide the
SegmentId for the relevant dialogues in the
transcript that were summarized. This helps users validate accuracy of the summary in your application. Like explainability, providing
traceability and transparency for AI-generated insights is consistent with Responsible AI principles.
Providing these references along with the summary notes to clinicians or medical scribes helps foster trust and encourage the
safe use of AI in the clinical settings.
For an example of a Clinical Documentation file from a transcription job, see the a Clinical Documentation file example in Transcription job output examples. For an example of a Clinical Documentation file from streaming, see the a Clinical Documentation file example in Streaming transcription output examples.
GIRPP template sections
The GIRPP insights template includes the following sections.
| Section | Description |
|---|---|
|
Goal |
The identified problem, challenge, or behavior that needs to be addressed through treatment. |
|
Intervention |
The specific treatment, method, or technique used by the clinician to help the patient address the identified goal. |
|
Response |
How the patient responded to the intervention, including their participation level, reactions, and feedback. |
|
Progress |
The clinician's assessment of movement toward treatment goals, including observations of patient improvement or barriers. |
|
Plan |
The next steps in treatment, including future interventions, homework assignments, and referrals. |
