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 40 notes/month free forever
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 Update, 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, Imaging Report, 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, doctor information, and PDF templates.

Doctor Information

Click the ⚙️ Settings icon (gear icon) in the header to open the Settings modal. The modal has three tabs: General (language preferences and account info), Profile (your doctor information and print settings), and Templates (PDF report templates). Your professional details create a letterhead that is automatically used when printing Medical Reports, Referral Letters, Prescriptions, and Investigations.

Fields Available:

• Doctor Name (required for reports)
• Title/Position (e.g., Professor, Consultant)
• Specialty (e.g., Cardiology, Internal Medicine)
• Institution/Affiliation
• License Number (optional)

Clinic Logo

Upload your clinic or practice logo. The logo appears centered in your bilingual print letterhead between the Arabic and English headers. The logo upload area is on the Profile tab in Settings.

• Supported formats: PNG, JPEG, WebP, SVG (max 2 MB)
• Upload methods: Click to browse or drag and drop your logo file
• Preview: A preview of your logo appears after upload so you can verify it looks correct
• Remove: Click the "Remove logo" button to delete your current logo
• Cloud sync: Your logo is stored securely and syncs across all your devices

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, Word (.docx), 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 CDA
• 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, Word (.docx), 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. When you print, your bilingual letterhead is automatically applied — Arabic on the right, English on the left, logo centered, with your clinic addresses in the footer.

Perfect for:

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

Referral Letter

Creates a professional referral letter to another specialist with your bilingual letterhead. 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 WhatsApp chat conversations 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
• Read shared document photos (lab reports, imaging reports, prescriptions)
• Create a chronological timeline of clinical events
• Generate a comprehensive case summary with Clinical Snapshot

Imaging Report

Generates professional radiology and imaging reports from dictation. Perfect for radiologists, imaging centers, and any specialist who needs to document imaging findings.

Template-Aware Processing

• With Template: Upload PDF templates in Settings → Templates tab. When you click Imaging Report, select your template and the AI follows it EXACTLY - preserving headings, formatting, and tables. See PDF Templates for setup instructions.
• Without Template: Uses the standard radiology report structure shown below

Standard Structure (when no template provided):

• EXAMINATION: Type of study performed
• CLINICAL INDICATION: Why the study was ordered
• TECHNIQUE: How the study was performed
• COMPARISON: Previous studies for comparison
• FINDINGS: Detailed findings organized anatomically
• IMPRESSION: Numbered conclusions

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)
• Page Size: A4 or A5 (configurable in Settings → Profile → Print Settings)
• Print Mode: Full letterhead or Content-Only (for pre-printed stationery)

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)
• Page Size: A4 or A5 (configurable in Settings → Profile → Print Settings)
• Print Mode: Full letterhead or Content-Only (for pre-printed stationery)

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 Update

Update your existing note using voice commands without regenerating everything. Add new information, modify sections, or remove content - all by speaking.

How It Works:

1. Generate your medical note first
2. Click "🎤 Voice Update" — button turns red: "⏹️ Stop & Update"
3. Speak your update (e.g., "Add blood pressure 140 over 90" or "Remove the allergy to penicillin")
4. Click "⏹️ Stop & Update" when done, or it will auto-stop after 30 seconds
5. Watch the button progress:
   • "🎤 Transcribing..." — converting speech to text
   • "📝 Updating note..." — AI applying your changes
6. Green notification appears: "✅ Note updated!"
7. Button returns to "🎤 Voice Update" — ready for more updates

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.

My Patient Records

Build your own patient registry directly within CDA. Save clinical notes to a Google Sheet on your own Google Drive — searchable, organized, and completely under your control. No EMR needed.

Connecting Google Drive

1. Click 📋 My Records in the navigation bar (desktop) or tap the My Records tab (mobile)
2. Click Connect Google Drive
3. Sign in with your Google account and grant permission
4. A Google Sheet called "AI4Docs — My Patient Records" is automatically created in your Drive

Saving & Managing Notes

After generating a clinical note, a 💾 Save button appears in the output area:

1. Click 💾 to open the save dialog
2. Search for an existing patient or click + New Patient
3. For new patients: enter the patient name (required), phone number and date of birth (recommended)
4. Click Save — the note is saved as Markdown to your Google Sheet

If you recently viewed a patient in My Records, they'll be auto-selected when you save — no need to search again for follow-up visits.

Adding Patients Without a Note

Click + Add Patient in the My Records panel to register a patient before their visit. This creates a patient entry without any clinical notes attached.

Editing Patient Details

Open a patient's record and click ✏️ Edit to update their name, phone number, or date of birth.

Searching for Patients

Use the search bar in My Records to find patients by:

• Name — supports Arabic name normalization (أحمد = احمد = أحمد), so you'll find patients regardless of how diacritics or letter forms were typed
• Phone number — partial match (e.g., type "0100" to find all numbers starting with 0100)
• Date of birth — search by year (e.g., "1985") or partial date (e.g., "22/03")

Loading Previous Visits

One of the most powerful features — load a patient's history before a follow-up visit:

1. Open My Records and find the patient
2. Click 📥 Load to Previous Visits to load up to 15 previous notes into the Previous Visits input section
3. The AI will use this context to generate a more informed follow-up note

You can also load a single note by opening it and clicking Load to Previous Visits at the bottom.

Viewing Saved Notes

Click on any patient to see their visit history, then click on a visit to view the full note — rendered with proper formatting (headings, bullet points, tables).

Google Sheet Structure

Your "AI4Docs — My Patient Records" Google Sheet contains two tabs:

• PatientRegistry — Patient ID, Name, Phone, Date of Birth, Last Visit Date
• ClinicalNotes — Note ID, Patient ID, Visit Date, Note Type, Clinical Note (Markdown)

You can open this sheet anytime in Google Sheets to view, edit, or share your records. The sheet is yours — you own it completely.

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 to print your document or save it as a PDF.

Word Export (.docx)

Click the Word button to download your note as a Microsoft Word (.docx) file. The export calls the backend to generate a properly formatted Word document that you can open in Microsoft Word, Google Docs, or any compatible word processor.

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

PDF Templates

CDA supports custom PDF templates for generating reports in your exact format. This feature is perfect for radiology centers, clinics, and practices with specific formatting requirements.

Supported Document Types

Templates work with four documentation types:

• Imaging Report: Radiology and imaging reports
• Dictation: Custom dictation outputs
• Medical Report: Formal medical reports
• Referral Letter: Professional referral letters

How to Add Templates

1. 1 Click the ⚙️ Settings gear icon to open the Settings modal
2. 2 Select the Templates tab
3. 3 Click + Upload PDF Template
4. 4 Enter a name for your template (e.g., "MRI Brain Protocol")
5. 5 Upload a PDF file (max 1 MB per template)
6. 6 Click Save Template

Using Templates

When you click Imaging Report, Dictation, Medical Report, or Referral Letter:

• If templates exist: A selector appears letting you choose which template to use (or "No Template" for standard format)
• If no templates: The button generates directly using the standard format

Managing Templates

• Edit: Click the "Edit" button next to any template to rename it or replace the PDF
• Delete: Click the "✕" button to remove a template
• Add more: No limit on the number of templates you can save

Best Practices

• Use clear, descriptive names (e.g., "CT Chest Protocol", "Ultrasound Abdomen")
• Keep PDF templates under 1 MB for best performance
• Use templates with clear section headings for best AI interpretation
• Test each template with a sample dictation to verify formatting

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)

EMR Export Options

In the Settings → General tab, under "EMR Export Options," you can control what is included when exporting notes to Smart EMR:

• Include Prescription: When checked, the prescription section is included in the exported note sent to Smart EMR
• Include Orders/Investigations: When checked, the ordered investigations section is included in the exported note

EMR API Key & Smart EMR

If you have a paid CDA subscription (Starter or above), the Settings → General tab shows your EMR API Key and a Clone Smart EMR button.

• API Key: A unique key in the format emr_xxxxxx-xxxxxx-xxxxx_xxxxxx. Use the Copy button to copy it for pasting into your Smart EMR Settings.
• Clone Smart EMR: Click this button to create your own copy of the Smart EMR app. See the Smart EMR Documentation for full setup instructions.

Multi-Tab Sessions

Open multiple browser tabs to work on different patients simultaneously.

Install as App (PWA)

The Clinical Documentation Assistant (CDA) 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) - available to ALL users including free tier!

Usage & Credits

What Counts as a Note (Uses Credits):

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

Unlimited (Free) Actions:

• Edit Mode (auto-save), Voice Update, 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 current plan, usage progress bar, renewal date, extra credits, and links to "Change Plan" and "Manage Subscription" (Stripe billing portal).

Account Management

Open Settings (⚙️ gear icon) → General tab to manage your account. Here you can:

• View your plan: See your current subscription tier, usage progress bar, and renewal date
• Change Plan: Upgrade or downgrade your subscription
• Manage Subscription: Opens the Stripe billing portal where you can update payment methods, view invoices, or cancel
• Log Out: Sign out of your account

Reset All Button

The Reset All button is a large, full-width red button at the top of the left column (Capture tab on mobile). It reads "Reset All Fields — New Patient" with a warning icon, displayed in bright red with white bold text — it is prominent and hard to miss. 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.