Form structure best practices for AI Scribe

How to Design Effective Forms for Maximum AI Documentation Accuracy

In this article

Overview

AI Scribe analyzes your session transcripts to automatically populate custom form fields, dramatically reducing documentation time. However, the structure and organization of your forms directly impacts the accuracy and usefulness of AI-generated notes.


This guide helps you design forms that work seamlessly with AI Scribe while maintaining clinical utility. Poor form structure can result in:

  • Incorrect or missing information in notes
  • Old data inappropriately carrying forward to new visits
  • Confusion about which fields AI Scribe should fill
  • Reduced documentation accuracy and clinical value

How AI Scribe Works with Your Forms

When AI Scribe processes a transcript:

  1. Analyzes each field individually based on its label and type
  2. Uses existing data (prefills, copied values) as context
  3. Determines what to populate based on transcript content vs. existing data
  4. Follows specific rules for different field types

The key insight: AI Scribe sees your form structure exactly as you've built it – if the structure is confusing to a human, it will be confusing to AI.

Understanding Field Types

Understanding when to use each field type is crucial for AI Scribe success. Each type behaves differently and serves specific purposes.


Regular Fields (Default)

  • What they do: Start blank for each new note
  • When to use: Information that should be fresh for each visit
  • AI Scribe behavior: Fills only if transcript contains relevant information
  • Examples:
    • "Chief complaint for today's visit"
    • "Current symptoms discussed"
    • "Today's session focus"

Pre-fill

  • What this does: Copy the ENTIRE previous charting note (same template only)
  • When to use: When you want the whole previous note as a starting point
  • AI Scribe behavior: Updates prefilled content based on new transcript
  • Examples:
    • Progress notes where you want to build on previous content
    • Treatment plans that evolve over time

Copied Fields

  • What they do: Copy the LATEST response to the same question from ANY form
  • When to use: Information that rarely changes but might need updating
  • AI Scribe behavior: Updates only if transcript contradicts the copied value
  • Examples:
    • "Patient's primary health goals"
    • "Preferred communication style"
    • "Background medical history"

⚠️ Critical Warning: Do NOT use copied fields for visit-specific information!


Smart Fields

  • What they do: Auto-populate from the patient's profile (name, DOB, medications, etc.)
  • When to use: Profile information that stays current across the platform
  • AI Scribe behavior: Generally doesn't modify these (they sync with patient profile)
  • Examples:
    • Patient name, date of birth
    • Current medications list
    • Contact information

Form Structure Best Practices

1. One Question, One Field


❌ Incorrect Structure:

Field 1 (Header): "SUBJECTIVE ASSESSMENT"
Field 2 (Text - no label): [empty text box]

✅ Correct Structure:

Field 1 (Text): "Subjective assessment - Document patient's reported concerns, symptoms, and experiences discussed in today's session"

Why this matters: AI Scribe needs clear, descriptive labels to understand what information belongs in each field. Header fields without corresponding labeled text fields create confusion.


2. Use Descriptive Field Labels

Your field labels act as instructions to AI Scribe. Reference our Field Labeling Best Practices Guide for detailed guidance on writing effective labels.


❌ Vague labels:

  • "Notes"
  • "Assessment"
  • "Update"

✅ Clear, specific labels:

  • "Document specific CBT techniques discussed and patient responses during today's session"
  • "Patient's self-reported mood and anxiety levels on a scale of 1-10"
  • "Progress toward treatment goals established in previous sessions"

3. Organize Fields Logically

Group related fields together using form sections:

  • Session Opening: Check-in, current concerns, mood
  • Clinical Assessment: Symptoms, observations, measurements
  • Treatment: Interventions used, patient responses, homework
  • Planning: Next steps, goals, medication adjustments

4. Control Form Complexity

Recommended limits:

  • Total fields: 20-40 fields maximum per form
  • Text fields: 10-15 substantial text fields
  • Field sections: 3-6 logical sections

Forms with 50+ fields often overwhelm both providers and AI Scribe, leading to incomplete or inaccurate documentation.


5. Choose Appropriate Field Types

For information that changes every visit:

  • Use regular fields
  • Examples: Today's session content, current symptoms, visit-specific assessments

For information that rarely changes:

  • Use copied fields sparingly and thoughtfully
  • Examples: Long-term goals, background history, care preferences

For information that should build over time:

  • Use prefilled fields with clear labels about updating vs. preserving content
  • Examples: Treatment plan evolution, ongoing care notes

Testing Your Forms


1. Start Small

  • Begin with 10-15 essential fields
  • Test with a few sample appointments
  • Gradually add fields as needed

2. Review AI-Generated Content

After AI Scribe processes sessions:

  • Check if information appears in logical fields
  • Verify visit-specific content isn't being overridden by copied data
  • Ensure field labels are generating the expected responses

3. Monitor Field Usage

  • Note which fields AI consistently fills vs. leaves blank
  • Identify fields that get incorrect or irrelevant information
  • Adjust field labels and types based on patterns

4. Gather Provider Feedback

  • Ask colleagues to review AI-generated notes
  • Identify fields that need clearer labels or different types
  • Refine based on clinical workflow needs

Quick Reference

Field Type Decision Tree


Ask yourself: "How should this information behave across visits?"

  • Fresh each time → Regular field
  • Build on previous notes → Prefilled field
  • Rarely changes, but might need updates → Copied field
  • Comes from patient profile → Smart field

Red Flags for AI Scribe Problems

  • Forms with 50+ fields
  • Many copied fields for visit-specific information
  • Header fields without corresponding labeled text fields
  • Vague or generic field labels
  • Mixed field types without clear purpose

Green Flags for AI Scribe Success

  • 20-40 total fields maximum
  • Clear, specific field labels that reference our labeling guide
  • Logical field organization using sections
  • Appropriate field type selection
  • Regular testing and refinement based on results

Additional Resources


Writing Effective Form Labels for AI-Generated Charting Notes

Copied, Prefill, and Smart Fields Guide

Did this answer your question? Thanks for the feedback There was a problem submitting your feedback. Please try again later.