Clinical Documentation Assistant - Complete User Guide

Introduction

AI4Docs.AI is an AI-powered clinical documentation assistant that transforms your patient consultations into structured, professional medical notes in seconds. Whether you speak Arabic, English, French, or any other language during consultations, the AI understands and can produce documentation in 13 languages - including full right-to-left (RTL) support for Arabic.

Quick Start Guide

1. 1 Sign Up: Create your account (email or Google) - get 7-day free trial with full access
2. 2 Record or Type: Speak with your patient (any language) or type your notes
3. 3 Add Files: Upload lab results, imaging, or other documents if available
4. 4 Generate: Click "First Visit" or other documentation type
5. 5 Review: Always review the generated note before use
6. 6 Export: Copy to EMR, Share, or Print → Save as PDF

Mobile Experience

CDA is optimized for mobile devices with a streamlined interface designed for on-the-go documentation. The modern segmented control tabs (iOS/Android style pill-shaped tabs) make navigation intuitive and familiar.

Mobile Tabs (Segmented Control)

On mobile, the interface uses a modern segmented control with two tabs:

• Capture Tab: All your inputs in one place - note type selection, voice recording, typed notes, file uploads, and custom instructions. The Reset All button and Generate button are here too.
• Note Tab: This is where you view and manage your generated documentation - your output, editing tools (Edit Mode with auto-save, Voice Add, Revert), and export options (Copy, Share, Print).

Note Type Selection

On the Capture tab, select your documentation type from the dropdown menu at the top. Choose from First Visit, Follow-up, Dictation, Recap, Medical Report, Referral Letter, Chat to Notes, or Clinical Snapshot. Then add your inputs and tap the Generate button to create your note.

Sticky Generate Button

The generate button stays fixed at the bottom of your screen while you scroll through input sections - always one tap away when you're ready to generate your note.

Account Setup

Creating Your Account

• Email & Password: Enter your email and create a secure password. Use the 👁 eye icon to verify your password.
• Google Sign-In: One-click sign up using your Google account for convenience and security.

Your account allows you to track usage and upgrade plans. Click the ⚙️ Settings gear icon to access your account info, language preferences, and doctor information.

Doctor Information

Click the ⚙️ Settings icon (gear icon) in the header to open the Settings modal. The modal has two tabs: General (language preferences and account info) and Profile (your doctor information). Your professional details create a letterhead that is automatically used in both Medical Reports and Referral Letters.

Fields Available:

• Doctor Name (required for reports)
• Title/Position (e.g., Professor, Consultant)
• Specialty (e.g., Cardiology, Internal Medicine)
• Institution/Affiliation
• License Number (optional)
• Additional Letterhead Information (e.g., office address, phone, email, qualifications)

1. Patient Conversation

This is the most powerful feature - record your actual patient consultation in any language.

Two Options:

📁 Upload Tab

• Click the upload area or drag & drop an audio file
• Supports all common audio formats (MP3, WAV, M4A, WebM, Opus, etc.)

🎤 Record Tab (Preferred)

• Click Start Recording to begin - the button turns red with a pulse animation while recording
• Speak naturally with your patient
• Use Pause to temporarily stop (e.g., during examination) - button shows solid red; Resume to continue
• Click Stop Recording when finished

2. Doctor's Notes

A text area for typing additional information such as:

• Physical examination findings
• Investigation results you want to highlight
• Requested investigations and treatment plan
• Quick observations not captured in audio
• Medical abbreviations (AI understands: HTN, DM, SOB, AF, etc.)

Abbreviations: Use "DM+" for diabetes positive, "DM-" for no diabetes. Same for "HTN+" (hypertension positive), "HTN-" (no hypertension). Always use + or - to be explicit and avoid ambiguity.

3. Doctor's Dictation

A versatile input for your own voice - not the patient conversation. Dictation is much more powerful than just summarizing cases.

When to Use Dictation vs Patient Conversation:

• Patient Conversation: The actual consultation recording with the patient
• Dictation: Your own voice input - summaries, findings, results, or custom note types

Like patient conversation, you can upload an audio file or record directly in the app.

Advanced Dictation Workflows

Dictation is extremely flexible. Here are powerful ways to use it:

4. Investigation Files

Upload up to 400 files per session to be analyzed and included in documentation.

Supported File Types:

• Images: JPEG, PNG, GIF, WebP, BMP (photos of reports, scans)
• Documents: PDF, plain text files
• Audio: MP3, WAV, M4A, Opus, WebM, OGG, FLAC
• ZIP Files: Including WhatsApp chat exports with media

Three Input Methods:

📁 Upload Tab

• Click to select files or drag & drop multiple files
• See file count update (0/400)
• Remove individual files with the "Remove" button

📷 Camera Tab (Mobile)

• On mobile devices, capture lab reports or imaging results directly with your camera
• Ideal for paper results - snap a photo and it's included in your documentation

📤 Share to App (Android PWA Only)

• After installing CDA as a PWA (Add to Home Screen), it appears as a share target
• From any app (Gallery, Files, WhatsApp), tap Share → select ClinDoc
• Files automatically go to Investigation Files
• Note: This feature is not available on iOS due to Apple's PWA restrictions

5. Previous Visits (For Follow-ups)

This optional section provides context for follow-up visits. The AI uses this information to understand what has changed since the last visit.

Three Input Methods:

📁 Upload Tab

• Upload previous visit notes as PDFs, images, or text files
• Supports up to 20 files

📝 Text Tab

• Paste or type a recap from previous visits
• Copy from your EMR or previous notes

🎤 Audio Tab

• Record or upload an audio summary of previous visits
• Quickly dictate the relevant history

6. Custom Instructions

This powerful feature lets you customize the AI output for any specific need.

Two Input Methods:

📝 Type Tab

Type your instructions directly.

🎤 Voice Tab

Record your instructions - they'll be transcribed and added to the text area.

Example Uses (with recommended buttons):

First Visit

Generates a comprehensive initial consultation note with all standard sections:

• Clinical Snapshot (at the top - concise summary)
• Chief Complaint
• History of Present Illness (HPI) - in bullet points
• Past Medical History
• Surgical History
• Current Medications
• Allergies
• Family History
• Social History
• Review of Systems
• Point-of-Care Diagnostics (if applicable)
• Physical Examination Findings
• Investigations (with full results)
• Assessment & Plan

Follow-up Visit

Creates a focused follow-up note documenting only what has changed since the last visit.

The follow-up note includes:

• Clinical Snapshot (at the top - concise summary)
• Reason for Follow-Up
• Interval History (changes since last visit)
• Current Medications (marking NEW, CONTINUED, or DISCONTINUED)
• Physical Examination (today's findings only)
• New Investigations
• Assessment (response to treatment)
• Updated Plan

Dictation

Generates a structured clinical note from your dictated audio (Section 3 input). This is the most versatile output button.

Use Cases:

• Summarizing a case in your own words (SOAP format)
• Creating operative notes (with custom instruction)
• Organizing dictated lab/imaging results
• Any custom note type via Custom Instructions

Default output: SOAP-format clinical note. Combine with Custom Instructions for other formats.

Recap

Extracts and compiles information from handwritten notes, PDFs, and other documents into a chronological timeline. Ideal for:

• Creating a patient summary from multiple visit records
• Compiling a problem list
• Tracking medication changes over time
• Preparing for multidisciplinary team meetings
• Digitizing years of handwritten notes

Output Structure:

• Clinical Snapshot (at the top - concise summary)
• Chronological Timeline: All clinical events with dates in UK format (DD/MM/YYYY)
• Problem List: All conditions with resolved items highlighted
• Medication List: Current and past medications with discontinued items highlighted
• Surgeries: Surgical history with dates when available
• Procedures: Non-surgical procedures with dates

Medical Report

Generates a formal "To Whom It May Concern" medical report with your letterhead (from Doctor Information section).

Perfect for:

• Insurance claims
• Legal documentation
• Sick leave certificates
• Fitness to work assessments

Referral Letter

Creates a professional referral letter to another specialist. Use Custom Instructions to specify:

• The specialist you're referring to
• The specific question or reason for referral
• Any urgency level

Chat to Notes

One of the most powerful features - converts chat conversations (WhatsApp, Telegram, or any messaging app) with patients into clinical documentation.

How to Export WhatsApp Chat:

Android:

1. Open the chat with your patient
2. Tap the 3 dots (top right) → More → Export chat
3. Select Include media
4. Save the ZIP file

iOS (iPhone):

1. Open the chat with your patient
2. Tap the patient's name at the top
3. Scroll down → tap Export Chat
4. Select Attach Media
5. Save the ZIP file

Then in CDA:

1. Upload the ZIP file to Investigation Files (Section 4)
2. Click the Chat to Notes button

The AI will:

• Extract all text messages (with automatic de-identification)
• Transcribe all voice notes
• Analyze shared images (lab results, imaging)
• Create a chronological timeline of clinical events
• Generate a comprehensive case summary with Clinical Snapshot

Smart Case Review

Get AI-powered literature review tailored to your medical note - providing differential diagnoses, diagnostic reasoning, and evidence-based recommendations.

The Smart Review Includes:

• Differential Diagnosis: Ranked by likelihood with supporting evidence from your note
• Diagnostic Reasoning: Key distinguishing features between differentials
• Evidence-Based Assessment: Recommendations with guideline references
• Red Flags: Critical conditions to rule out
• Recommended Investigations: With rationale
• Treatment Options: Based on current clinical guidelines
• References: Citations to relevant guidelines (ACC/AHA, NICE, etc.)

Clinical Snapshot

A concise summary that appears at the start of most note types, or can be generated as a standalone button.

Output Structure:

• Active Problems: All active diagnoses/conditions with severity and control status
• Key Findings: Most important clinical findings, recent significant test results, critical examination findings
• Action Plan: Immediate actions needed, pending investigations, treatment changes required
• Summary: One comprehensive sentence summarizing patient demographics, main conditions, and current clinical status

Standalone Use Cases:

• Shift handovers
• Quick patient reviews
• MDT meetings
• Emergency department summaries
• Pre-operative assessments
• Quick reference during rounds

Prescriptions

Generates a prescription from your medical note with patient instructions in your chosen language. The prescription includes all medications (existing and new) - clearly labeled so you can identify what was added.

Options:

• Language: Select the language for patient instructions (in Settings → General Tab)

Investigations

Extracts ordered investigations from your medical note's Plan section and formats them with appropriate patient instructions.

Options:

• Language: Select the language for test names and patient preparation instructions (in Settings → General Tab)

Output includes:

• Test names in the selected language
• Special preparation instructions (fasting, timing, etc.) in the selected language
• Only adds instructions for tests that need them (e.g., PSA, fasting glucose)

Edit Mode (Auto-Save)

After generating a note, you have full editing capabilities with automatic saving:

Edit Mode (✏️ Button)

• Click "✏️ Edit Mode" to enable rich text editing
• A formatting toolbar appears with: Bold, Italic, Headings, Lists, Indent/Outdent, Undo/Redo
• Make any changes you need
• Click anywhere outside the editor or click "👁️ View Mode" - your changes auto-save!

Revert (↩️ Button)

Voice Add

Add information to an existing note using voice without regenerating everything.

How It Works:

1. Generate your medical note first
2. Click "🎤 Voice Add" — button turns red: "⏹️ Stop & Add"
3. Speak the information you want to add (e.g., "Blood pressure 140 over 90")
4. Click "⏹️ Stop & Add" when done — recording won't stop on its own
5. Watch the button progress:
   • "🎤 Transcribing..." — converting speech to text
   • "📝 Adding to note..." — AI placing in correct section
6. Green notification appears: "✅ Voice note added to medical note!"
7. Button returns to "🎤 Voice Add" — ready for more additions

Ask the Note (Q&A)

Query your medical note by typing or speaking a question.

How to Use:

1. Type your question in the Q&A bar, or click 🎤 to speak it
2. Click "Ask"
3. A popup shows the answer extracted from your note
4. Options: Copy the answer, Add to Note, or Back

Example Questions:

• "What was the blood pressure?"
• "What medications were prescribed?"
• "What is the diagnosis?"
• "When is the follow-up?"

Powerful Use Cases for Long Notes (Chat to Notes/Recap):

For very long outputs like Chat to Notes or Recap, Ask the Note helps extract specific data:

• "What were the urine culture organisms over time?"
• "What is the trend of PSA levels?"
• "Show creatinine levels over time"
• "List all blood glucose readings"

Add to Note

Several features can be appended to your main medical note:

• Smart Review: Add differential diagnosis and recommendations
• Investigations: Add the investigation list
• Prescriptions: Add the prescription list
• Q&A Answers: Add question/answer pairs

Click "➕ Add to Note" after generating any of these to append them to your main documentation.

Copy to EMR

Click the Copy button to copy the note to your clipboard. Paste directly into your EMR/EHR system.

The copy is formatted text (rich text) - it preserves headings, bold text, and bullet points in most EMR systems that support rich text pasting.

Print / Save as PDF

Click the 🖨️ Print button and select "Save as PDF" in your browser's print dialog to create a PDF document.

Share

Click 📤 Share to use your device's native sharing functionality (available on mobile and some desktop browsers).

The shared content is plain text formatted with capitalization for headings and hyphens instead of bullet points - optimized for messaging apps and simple text fields.

Language Settings

CDA features two separate language controls for maximum flexibility, accessible via the Settings gear icon (⚙️) in the header.

Two Language Dropdowns (in Settings → General Tab)

Click the Settings gear icon, then select the General tab to access language preferences. Your choices auto-save immediately when you select a new option - no save button needed:

• Medical Note Language: Controls the language of the entire clinical note output (headings, content, Clinical Snapshot)
• Patient Instructions Language: Controls the language of prescription instructions and investigation preparation instructions

Output Languages (13 Available)

English, Arabic, French, Spanish, German, Italian, Hindi, Chinese, Russian, Portuguese, Japanese, Korean, Swahili

Billing Codes (ICD-10/CPT)

Check the Include ICD-10/CPT Billing Codes checkbox before generating a note to get suggested billing codes appended to your documentation.

What the Checkbox Does:

When enabled, the AI analyzes your clinical data and suggests appropriate billing codes:

• ICD-10 Diagnosis Codes: Primary and secondary diagnoses with clinical evidence from your notes
• CPT Procedure Codes: For any procedures performed or planned (e.g., imaging, biopsies)

When to Use:

• Insurance billing preparation
• Practice revenue cycle optimization
• Documentation completeness checks
• Primarily useful for USA and Gulf markets (other regions may use different coding systems)

Multi-Tab Sessions

Open multiple browser tabs to work on different patients simultaneously.

Install as App (PWA)

The Clinical Documentation Assistant (ClinDoc) is a Progressive Web App that works like a native app on your device.

Installation:

iOS (iPhone/iPad):

1. Open clinic.ai4docs.ai in Safari
2. Tap the Share button
3. Select "Add to Home Screen"

Android:

1. Open clinic.ai4docs.ai in Chrome
2. Tap the menu (three dots)
3. Select "Install app" or "Add to Home Screen"

Desktop (Chrome/Edge):

1. Look for the install icon in the address bar
2. Click "Install"

Privacy & Data

AI4Docs.AI is built with privacy as a core principle:

• Zero Storage Policy: Patient data is processed in memory and never stored on our servers
• Recordings in RAM: Audio recorded in the app stays in your computer's memory and is never saved to disk
• Automatic De-identification: Names, phone numbers, and other identifiers are automatically stripped from outputs
• Session-Based: Each browser tab session is independent; closing the tab clears most data (Doctor's Notes and Custom Instructions persist in browser storage)

Consent & Recording

The app does not record automatically - you must explicitly click "Start Recording" to begin.

Review Before Use

Subscription Plans

Extra Credits: $25 for 100 notes (never expire)

Usage & Credits

What Counts as a Note (Uses Credits):

• First Visit, Follow-Up, Dictation, Recap
• Medical Report, Referral Letter
• Chat to Notes
• Smart Case Review
• Clinical Snapshot

Unlimited (Free) Actions:

• Edit Mode (auto-save), Voice Add, Revert
• Prescriptions, Investigations
• Q&A (Ask the Note)
• Copy, Print, Share
• Edit Mode

Check your usage in the Settings modal (click the ⚙️ gear icon). The General tab shows your plan, usage, and extra credits.

Reset All Button

The Reset All button is located on the Capture tab. Use it every time you begin documenting a new patient to ensure a clean slate.

Pro Tips

Troubleshooting

Voice recording not working?

• Allow microphone permission when prompted
• Check your browser's site settings
• Use Chrome or Edge for best compatibility

Edit Mode not working?

• Toggle to View Mode and back to Edit Mode, then try editing again
• This refreshes the editor state

Generation taking too long?

• Check your internet connection
• Large files (especially audio) take longer - use Pause/Resume while recording to keep files smaller
• Try with fewer files if uploading many

Session seems stuck?

• Desktop: Press Ctrl+Shift+R (Windows) or Cmd+Shift+R (Mac) to force refresh
• iPhone/iPad: Settings → Safari → Clear History and Website Data
• Android: Chrome → Menu (⋮) → Settings → Privacy → Clear browsing data

Note generation failed or output looks wrong?

Still need help?

Contact us at support@ai4docs.ai - we typically respond within 24 hours.