Overview
CarePilot AI Scribe listens to your natural, conversational dialogue with patients and intelligently generates comprehensive documentation without having to type or click anything in Athena. To ensure all relevant clinical information is documented by CarePilot, think of your visit as an opportunity to educate your patient out loud. As you conduct your exam and share findings, CarePilot captures and organizes the information into the appropriate sections of your clinical note in Athena.
This guide outlines how to naturally communicate during visits to help CarePilot accurately capture and categorize clinical content.
CarePilot Introduction by Arete Network Services CEO Dr. Garret Rock
Managing your Day in CarePilot by Arete Network Services CEO Dr. Garret Rock
New Patient Visit Workflow
History of Present Illness (HPI)
No special phrasing required—CarePilot summarizes the HPI from your normal conversation with the patient.
Helpful to mention:
Specific onset dates for each complaint or symptom.
Duration, location, severity, and any modifying factors.
Review of Systems (ROS)
A default template with unremarkable findings is used. CarePilot will automatically update the ROS if abnormalities are mentioned during the visit.
Physical Examination
To optimize documentation, consider using brief statements to introduce each exam component. This helps CarePilot identify and tag the relevant findings correctly.
General Observation
Posture, gait, balance: Describe any clinically relevant abnormalities.
Helpful keywords: Antalgic gait, unsteady, sway, asymmetry, etc.
Neurological Examination
Begin with: “I’m going to perform some neurological tests.”
Mention findings during or after performing tests.
Helpful keywords: Deep tendon reflexes, sharp/dull, sensation, myotomes, strength testing, two-point discrimination.
Range of Motion (ROM)
Introduce with: “Let’s test your range of motion.”
Specify:
Region (e.g., cervical, lumbar, shoulder, knee, etc.) and laterality (right or left). Be sure to mention each joint before or after testing. For example, “range of motion in your cervical spine is all within normal limits”.
Limitations: Use terms like limited, decreased, mild/moderate/severe.
Helpful keywords: Hypomobility, hypermobility, stiffness, etc.
Orthopedic Testing
Start with: “I’m going to perform some orthopedic tests now.”
Name each test and describe findings clearly.
Example: “This is the Straight Leg Raise test. I’ll start on the right side. Do you feel pain, numbness, or tingling?” → “Now on the left side…”
If a positive test is noted, CarePilot will typically describe what a positive means. However, when you first begin using CarePilot and the AI is getting to know you, it is helpful to mention to the patient what the positive finding means.
Soft Tissue Palpation
Cue AI by stating: “Next is soft tissue palpation.”
Document muscle or tissue findings using clear language:
Example: “Your right trapezius is significantly spasmed. Is it tender when I put pressure on it?”
Mention laterality and structure: muscles, tendons, ligaments.
Spinal Palpation
Cue AI with: “Next is spinal palpation. I’m going to press on the spinous process of each lumbar vertebrae. Let me know if any are especially tender.”
Specify:
Noted motion restrictions or tenderness at the exact spinal segment (e.g., “L5 on the right feels restricted in motion, is it tender?”).
Other Physical Findings – Imaging
If reviewing imaging, start with: “Your X-rays show…” or “On your MRI we see…”
Speak to the patient naturally about findings—CarePilot captures this for the note.
Assessment and Plan
During your discussion with the patient, be sure to:
Mention specific diagnoses (e.g., “lumbar spondylosis at L4-5”) and distinguish between your leading diagnosis and differential diagnoses.
Explain your recommended care plan, including any treatments or therapies, number of visits and expected response to care, when a re-exam will be performed, and key progress points.
CarePilot will match your spoken diagnoses to a list of relevant ICD-10 codes and organize the plan accordingly.
Procedures
When performing a procedure, explain what you're doing as part of your dialogue with the patient. This helps ensure accurate documentation.
Examples:
“We’re doing trigger point therapy in the right trapezius muscle.”
“I’m performing chiropractic manipulation on C2 on the right and C5 on the left.”
Final Tip
Speak as if you're educating your patient throughout the visit. CarePilot is listening for clinical intent—clear, descriptive language helps generate the best possible documentation with minimal manual input.
Physical Exam Template Defaults
In the Physical Exam section, defaults for very common findings are documented. This eliminates the need to mention these findings UNLESS abnormalities exist.
Below are defaults for chiropractic exams.
General Appearance: The patient is alert and oriented x3, well-nourished and well-groomed, in no acute distress.
Psychiatric: Appropriate affect and behavior. Normal thought process and content.
Pupils: Pupils are equal in size, dilation and constriction response is normal.
Cranial Nerves: CN II-XII intact.
Posture: No clinically relevant antalgic or postural abnormalities detected.
Gait and Balance: No clinically relevant abnormalities in the patients gait or balance are detected.
Skin: No clinically relevant rashes, lesions, or abnormal pigmentation are detected.
Deep Tendon Reflexes: Biceps, triceps, and brachioradialis reflexes are 2+ and symmetric. Patellar and ankle reflexes are 2+ and symmetric.
Pathological Reflexes: No clonus in the wrist or ankle. Hoffman's sign is absent. Babinski's sign is absent.
Extremity Sensation: Light touch, two-point discrimination, and sharp/dull testing reveal no abnormal findings in the upper extremities or the lower extremities.
Myotomes: Myotome testing for C5-T1 are normal bilaterally. Myotome testing for L2-S2 are normal bilaterally.
[Please include any mentions of range of motion testing that was performed to the cervical spine, thoracic spine, lumbar spine, shoulder, elbow, wrist, fingers, hip, knee, ankle, foot or other joint. List the specific joint and right or left, and any joint restriction or hypermobility mentioned]
Orthopedic Tests: [please list all orthopedic tests performed and the findings of the tests including whether they were positive or negative and left or right]
Soft Tissue Palpation: [list muscles, tendons, and ligaments that are noted as spasmed, hypertonic, and/or tender]
Spinal Palpation: [list all spinal segments that are noted as restricted in motion or tender to palpation]
Review of Systems Defaults for New Patient Templates
General: No unexplained weight loss or gain, no fever, no fatigue.
Skin: No rashes, lumps, itching, dryness, or color changes. No abnormal hair or nail growth.
Head: No headaches, dizziness, or syncope. No history of trauma.
Eyes: No vision changes, pain, redness, or discharge.
Ears: No hearing loss, tinnitus, pain, infections, or discharge.
Nose: No discharge, congestion, epistaxis, or sinus pain.
Throat/Mouth: No sore throat, dental issues, hoarseness, dysphagia, or changes in taste.
Cardiovascular: No chest pain, SOB, palpitations, ankle swelling
Respiratory: No cough, wheezing, SOB
Gastrointestinal: No abdominal pain, nausea, vomiting, diarrhea, constipation, GERD, normal appetite
Genitourinary: No incontinence, difficulty urinating, hematuria, dysuria, or increased frequency
Musculoskeletal: No muscle aches, muscle weakness, joint pain, back pain, neck pain, difficulty walking
Neurologic: No numbness, weakness, seizures, loss of consciousness, dizziness, headaches, tremors, or gait dysfunction
Psychiatric: No anxiety, depression, insomnia, alcohol abuse, suicidal thoughts, mood swings or delirium
Additional Notes
Dry Needling Default Language
Dry needling using thin filament needles was performed to [muscles stated by provider] to reduce muscle spasm. All needles were removed from body tissues. Visual inspection yields no notable adverse response. No ill effects reported per patient subjective post intervention.
Prior to the procedure the risks and benefits of the procedure were verbally discussed with the patient. The patient was given the opportunity to ask questions regarding the procedure, the indications, and associated risks. The risks include but are not limited to pneumothorax, infection, and possible worsening of symptoms. The patient verbalized understanding of the informed consent and agreed to proceed with the dry needling procedure.
The patient tolerated the procedure well, was informed of the signs and symptoms of adverse reaction and instructed to contact the office immediately should any of these symptoms develop. Standard post-procedure care was discussed along with any restrictions.