AI scribes convert your spoken documentation of activities like vital signs, hygiene assistance, mobility support, and patient observations into text-based clinical notes. This frees up time to focus on direct patient care rather than manual documentation.

Start each documentation session by clearly stating the patient's identifier before dictating your notes. Remember to end one patient's documentation completely before beginning another to maintain clear separation between patient records.

Speak clearly about any observed changes in patient condition, including details about time, specific observations, and actions taken. These notes create a valuable record of your attentiveness and can be shared with supervising nurses.

Most AI scribes process healthcare terminology related to activities of daily living (ADLs), vital signs, mobility assistance, transfers, positioning, intake/output measurements, and common observations CNAs make during patient care. The more you use profession-specific terms, the better the documentation becomes.

After reviewing your AI-generated notes for accuracy, you can copy and paste them directly into your facility's electronic health record or patient management system. This seamlessly integrates your documentation with the broader nursing team's records.

Speak naturally about resident participation levels, mood, social interactions, and responses to activities or care. This documentation helps track important quality-of-life indicators and supports person-centered care planning.