The Emergency Medicine AI model generates clinical documentation from what you explicitly say while recording. To ensure optimal emergency department (ED) output from DAX or Dragon Copilot, speak your medical decision-making (MDM) aloud as a conversational clinical narrative during recording: your concerns, what you did, what you found, how you interpreted it, and why you chose the disposition.
Note
This guidance assumes that the Primary specialty setting in your DAX or Dragon Copilot Profile is set to “Emergency Medicine”. If you consult in the ED and aren't an ED clinician, select the Primary specialty that matches your practice for the best output for your consult notes and documents.
Recording best practices
Clear, comprehensive recordings help ensure the best possible documentation.
In your first recording(s), capture critical contextual information, including:
The chief complaint, key past medical history, and the historian providing the details.
Patient identifiers, such as age and gender, and any past medical history that should appear in the history of present illness.
Your observed findings that you didn't already verbalize, and any risk modifiers or limitations.
Add follow-up recordings at inflection points (results returned, reassessment and response to therapy, consults, and disposition changes).
Use additional recordings for initial evaluations, interval or workup updates, handoffs or conversations with care team members, and a final summary of the final impression, disposition, and critical care time (if applicable).
Verbalize timestamps as necessary (for example, “At 14:10…”). Times aren't inferred.
Each recording contributes to the transcript used to generate your clinical documents. More complete recordings can improve generated summaries and reduce time spent editing the final note.
Record clinical information inside or outside the exam room, whether it’s an ambient conversation or a private monologue. (Stop and restart recording as necessary to avoid capturing extraneous conversations.)
- Use private monologues to recap interactions outside the patient's room, capture sensitive findings, or document encounters with disoriented, comatose, nonverbal, or uncooperative patients.
Before recording, disable any Bluetooth device with a microphone that is connected to your mobile device.
Adjust Do Not Disturb settings to reduce interruptions while still allowing important secure chat and paging notifications.
While recording, ensure proper device placement so the microphone on the device isn't obstructed (for example, in your breast pocket upside down) to ensure clear recording.
What to include in your recordings
Follow these guidelines to ensure the information you want to include appears correctly in your clinical documents.
Assessment and differential: Name the diagnoses you are considering and the key risk and context modifiers that raise or lower concern (for example, immunocompromise, anticoagulation, recent surgery, or prior similar episodes). Include who provided the history and any limitations.
MDM chain (medical necessity): State the logic in sequence (concern or diagnosis → orders and therapy → results → your interpretation → next step). Include chronic conditions, social determinants of health (SDOH) that changed care, and any risk tools used (and how they influenced the disposition).
Orders: Verbally include the details of the medications given or ordered, and each lab or imaging study ordered if you want them included in your documents.
Interpretation and records: If you independently interpret a test, say “I independently interpreted …” and then state the finding. Also state which internal or external records you reviewed, and the specific relevant information obtained.
Disposition: Once decided, clearly state whether the patient is discharged, admitted, placed in observation, or transferred. Include follow-up and return precautions. Document shared decision-making (risks, benefits, alternatives, and patient preferences) when applicable.
Critical care: Critical care time isn't inferred. Verbalize the total minutes and use compliant phrasing when applicable (for example, excluding separately billable procedure and documentation time).
Workflow considerations
Interval or workup notes: When “Emergency Medicine” is the Primary specialty, additional ambient recordings appear as workup notes in a separate section of the Assessment & Plan summary. Verbalize the time at the start of the recording if you want a timestamp included.
Multiple contributors: Only one person can contribute recordings to a single note. Other clinicians can create separate notes for the same patient on the same day.