DocSense | User Guide

Purpose

This article provides guidance for the use of DocSense by providers using DocNow. 

Audience

DocNow users. 

Overview

DocSense is an AI-powered medical documentation assistant integrated into the DocNow platform that transforms voice dictations into structured, clinically relevant medical notes. The system uses advanced Large Language Models (LLMs) to process audio recordings and generate comprehensive medical documentation that follows standard clinical templates.

There is no dedicated recording equipment necessary other than a device that has a built in microphone. 

Table of Contents

• Admin Set Up
  • Template Configuration 
• Template Best Practices
• Provider Workflow
• Troubleshooting 

Admin Set Up 

Setting up DocSense for your practice involves a few steps, supported by your DocNow Implementation team:

1. Get started – Speak with your DocNow Implementation Specialist or Account Manager about using DocSense for your practice. 
2. Permissions enabled – Once you're ready to move forward, the DocNow Implementation team will enable the DocSense and Enhanced Templates permissions for your account. 
3. Enhance your templates – The Implementation team will work with your practice managers to enhance your templates (see Enhancing Templates below). This is required before any provider can use DocSense. 
4. Provider training – The Implementation team will train your providers on basic usage and best practices for DocSense. 
5. Go live – Once training is complete, providers can start using DocSense whenever they're ready. 

In addition to the setup above, each provider needs the DocSense user permission enabled on their account. Your Implementation team can help configure this, or your admin can manage it directly – for example, when onboarding new providers who will use DocSense. 

 

Enhancing Templates

*If you are a DocNow beta participant DocNow has already applied enhancements to your designated templates. 

Enhanced templates are required to use DocSense. If a provider opens a template that has not been enhanced, the DocSense button will be grayed out and unavailable. 

Enhancing a template applies tagging on the back end so DocSense can recognize every section and make edits in the right place. We recommend enhancing every template in your practice – with help from your Implementation team – so there's never any friction for providers who want to use DocSense. 

Enhancing a template does not change how it looks or works for providers. Carry forward, dot phrases, and dropdowns all continue to work exactly as before – this is primarily a back-end change with some small formatting adjustments. Once enhanced, a template keeps its enhanced formatting through future edits, as long as you don't add new sections. If you add a new section, refer to this guide or reach out to your account manager or Implementation team to make sure it's tagged correctly. 

An implementation team member from DocNow will assist you with making the following changes. 

1. Before applying enhanced formatting, make sure section headings stand alone on their own line, with no other information on the same line. This helps DocSense recognize what is a heading and what is not, so it never edits the heading itself – only the information underneath it. Example below: 

   Not compatible with DocSense: 
   HPI: ***

   Compatible with DocSense: 
   HPI: 
   ***
    

2. Open any template you would like to enhance from the admin portal. Select the Enhance Template button.  
   
   
    

3. After applying you will see visual indicators of what was applied - headers and footers of the note will be highlighted and separated, headings will be blue, dot phrases will be blue and underlined, and the sections underneath headers will have a spanning vertical line. 
   
   
    
4. To add or remove enhanced elements one by one, you can use the DocSense Labels option in your tool bar. The most common use of this would be to fix the formatting of a non system recognized heading. 
   1. Note how procedure was included in the section of Wound Assessment since it is not a system recognized heading. 
      
   2. For this example you would highlight the section, and then choose the Section label to remove the formatting, then correctly label Procedures as a heading before re-adding section labels. 
      
      Removing Section formatting
      
      
      Applying Heading formatting to Procedures
      
      Applying section formatting for each header - when applying section formatting you must associate the section to a matching heading
      
       
   3. When finished with changes make sure to save. At any point you may remove all enhanced template formatting by using the Remove Enhanced Template button at the top of the template editing screen. 

Template Best Practices

Dropdown Matching

DocSense matches dictation to dropdown options closely – generally requiring close to a 90% match for an option to be selected. If a provider's dictation is close but not a strong enough match, DocSense will add it as free text instead of selecting an option. To give providers more flexibility, consider adding a catch-all *** free-text line as one of the options in your dropdowns. 

Untagging Sections You Don't Need DocSense to Edit

When a template is enhanced, DocSense recognizes every tagged heading and may edit the content underneath it. If there are sections you don't want DocSense to touch, you can leave them untagged (or remove the tag with DocSense Labels). This simplifies what providers see and improves accuracy for the sections DocSense is editing. 

Examples: 

• Medications or Allergies – if these are populated from a PCC integration and don't need provider dictation to update them. 
• Hospital Course – if you only want it captured on the initial note, you can leave it untagged on follow-up templates. 
• Wound Assessment or Wound Plan – if these are already handled outside of DocSense. 

Your Implementation team can help you decide which sections to tag for your templates. 

 

Avoid Designing Templates That Need the Same Information Twice

DocSense will not populate the same dictated content into more than one template section, even if a template is designed to capture it in two places (for example, a summary of chronic conditions near the top of the note and a more detailed comorbidities list further down). If a provider dictates this information once, DocSense will only place it in one of the matching sections and leave the other blank. 

When designing or enhancing templates, avoid asking for the same information in multiple sections. If a template currently does this, providers will need to manually copy the information into the second location. 

 

Provider Workflow

DocSense dictation can be used in multiple ways, giving you flexibility in how you capture information:

• Ambient: Record the conversation between yourself and the patient (and others present). DocSense will parse the conversation and apply the relevant information to your note based on your note template.
• Direct Dictation: Dictate directly to DocSense without an ongoing conversation. This can be done before a visit (e.g. pre-charting a hospital course or HPI while reviewing documents) and/or after a visit to summarize the encounter. You may record multiple dictations for a single note, whether ambient, direct, or a combination of both.

One Time Set Up - Set Your Preferences 

1. Navigate to the DocSense tab within any open note and open settings 
   
   
   
   
   
   
    

1. Auto Apply: When enabled, DocSense automatically applies Template Preview content to the note editor after the initial processing completes. For subsequent changes when using DocSense and initial changes have already been applied, select “Apply to Template”.
    
2. Contextual Changes (Recommended enabled): When enabled, DocSense may modify existing default text in template fields to incorporate dictated content. When disabled, DocSense only appends content and does not alter existing text.
    
3. Drop Down Changes (Recommended enabled) When enabled, DocSense will attempt to select matching dropdown options in the note editor based on dictated content. When disabled, DocSense will only append content as text and will not interact with dropdown fields.
    
4. Conversational Script: When enabled, the transcript displays speaker-differentiated segments. Speaker detection is automatic.
    

Notes: 

Making any changes to your preferences will save these preferences for all future uses of DocSense. 

Record Your Content

1. Activate DocSense by selecting the DocSense icon near the top of the note. You may record in person patient visits for ambient dictation, or you may use direct dictation for pre or post visit charting. 
   
   Notes: 

   - You may need to alter browser settings to allow your browser to use your computer's microphone. 
   - If the DocSense icon is grayed out, it is likely because the template you are using is not enhanced for DocSense. Try selecting a different template. If the icon is still grayed out, contact your practice administrator. 
   - You can start recording with DocSense without choosing a template. 
   
   
   
   - The Template Preview tab is available as soon as you select a template – you don't need to make a full recording first. This lets you dictate just a few specific sections (using the Speech to Text icon on each section) without doing a full ambient or direct dictation. 
   
   While recording the DocSense icon will change to indicate that you are currently recording. A live waveform will also display, confirming that your audio is being captured. 
   
   

   Recording Recommendations: 

   • Enunciate words clearly.
   • Include template headers explicitly in your dictation to increase accuracy.
   • Dictate your drop down options verbatim for best results. 
   • Work in a quiet environment when possible. Since DocSense is designed to work in an ambient environment, it will pick up outside noise. Consider using a lapel microphone for speaker isolation in noisy environments. 
2. When you are finished recording select the Recording icon shown above to stop recording and process the audio you have recorded. 
3. You may record multiple transcriptions for a single note. 

Review, Edit, and Apply Your Content

1. To review your recording and how it was parsed navigate to the DocSense tab. View the Transcript at any time to see your verbatim dictation(s), and view the Template Preview to see how your transcript was parsed for your note and to make edits before applying. 
   
   
   
   
   
    

2. In the Template Preview sub tab you can review and apply the content that DocSense has created from your recording and where it has parsed it in the template you are currently using.

   • Use the arrows icon for Remap To Different Heading to move the given content to a different header.
   • Use the reverse icon for Revert DocSense Changes to remove the parsed content from this section.
   • Use the microphone icon for Speech to Text to record content for this specific header. This content is appended to the section and applied automatically – no separate Apply to Template step is needed for section-level recordings. 
   • Use your cursor to edit any of the text that was created for the given header.
   • The sections shown here can can be expanded by dragging the icon in the lower right area of each section.
   • Select Delete All to delete any current captured recordings for this encounter.

   3. When you have made your desired changes choose Apply to Template to apply the content of the Template Preview to your note in the note editor. 

   4. DocSense will place the parsed content into your note. It will fill out drop down menus, free text areas, and make contextual changes to preset text depending on the settings you have enabled. 

Notes: 

• DocSense will not overwrite or override data that has been pulled in from PCC in a dot phrase such as .meds@pcc 

Voice-Activated Dot Phrases

During your dictation, say “insert [dot phrase name]” to have DocSense insert that dot phrase into the relevant section. The dot phrase will appear in the Template Preview for you to review before applying, just like other dictated content. 

Note: Dot phrases are currently inserted at the bottom of the section – there isn't yet a way to control where within a section a dot phrase is placed (for example, under a specific diagnosis in Assessment & Plan). 

Troubleshooting 

Connection or Processing Errors

Symptoms: Recording button changes to Reconnecting... during recording or processing 
Causes: Internet connection disrupted while using DocSense 

Since it is used through DocNow web application, DocSense depends on a stable internet connection to function properly. 

If at any point your internet connection is disrupted during recording or processing of a DocSense dictation you will see the recording button change to Reconnecting...

Once you regain internet connection the audio that was recorded before the internet was lost can be processed by selecting Resume Processing. After the original audio is processed you may record more dictations if desired. 

Note: This reprocessing will only work for 24 hours after connection was lost until the audio is lost. Additionally, the audio that is recorded will only be available for processing on the same device that you were using when connection was lost. 

You may also see a message like "We could not transcribe your dictation. Please try again" if transcription times out or fails for a reason other than your internet connection. In this case, the same Resume Processing button can be used to resubmit your audio without re-recording. 

No DocSense Recording Icon

Symptoms: DocSense icon does not appear in the note 
Causes: DocSense not yet set up for your practice, or individual user permission not enabled 

Solutions:

• Ensure your practice admin has set DocSense up for your company and has enabled your individual user permission

 

DocSense Recording Icon Grayed Out

Symptoms: DocSense icon is visible but grayed out and cannot be selected 
Causes: Template in use has not been enhanced for DocSense 

Solutions:

• Try selecting a different template.
• If the icon is still grayed out after switching templates, contact your practice administrator to confirm the template has been set up for DocSense.

Symptoms: DocSense icon is grayed out specifically when continuing a follow-up note opened from Recent Notes, even though the template has been enhanced 
Causes: The note may be carrying forward an older version of the template from before it was enhanced for DocSense 

Solutions:

• Select the template fresh from your template library, rather than continuing from Recent Notes, to ensure you're using the current enhanced version.

 

Dropdown Selection Errors

Symptoms: Dropdown options not being populated correctly 
Causes: Dropdown feature not activated, unclear pronunciation, option name mismatch 

Solutions:

• Ensure dropdown toggle is activated before recording
• Speak clearly and mention options naturally during recording
• Use exact option names when possible
• Check dropdown options before recording
• Use manual selection if automatic population fails

 

Content Generation Delays

Symptoms: Long processing times for audio 
Causes: Large audio files, system load, network issues 

Solutions:

• Break long recordings into smaller segments
• Check internet connection stability
• Close unnecessary applications

 

Incomplete Content Generation

Symptoms: Missing sections or incomplete information 
Causes: Audio quality issues, unclear speech, system limitations, provider oversight 

Solutions:

• Manually review all generated sections for completeness
• Re-record unclear or missing sections
• Speak more clearly and slowly during recording
• Use section-specific regeneration for identified gaps
• Manually add missing information through editing

If you have questions or need further support, please contact [e-mail] or your Account Manager.