Document Creation#

Omnio is capable of creating comprehensive documents from the audio, tailored to your custom business needs. Some examples might include:

  • structured patient documentation from a medical dictation

  • customer interaction report from a call center conversation

  • management report with key action points from a business meeting

Below is an example of a medical document created by Omnio, which includes a letter for the patient, a structured medical report and a list of medications and assigned procedures.

Prompt#
Analyze the audio with the following components:
1. Letter for the patient: A summary of the encounter in a letter for the patient
2. Structured report: A summary of the encounter organized into the following sections:
  - History of Present Illness
  - General Exam
  - Physical Exam
  - Imaging Findings
  - Treatment Plan
3. Missing items: A list of items the doctor did not address with the patient.
4. List of medications: A list of medications and instructions the doctor prescribed for the patient if any in the form of a standard prescription.
5. List of orders: A list of any orders for x-rays, imaging, procedures or other tests that need to be created for the patient.

Letter for the Patient

Dear [Patient’s Name],

I hope this letter finds you well. During your recent visit, we discussed your ongoing back and leg pain issues following your previous surgery. We conducted a CT and MRI to assess the situation, which revealed some degenerative changes and issues with the screws in your spine. I believe that further surgery may be necessary to address these problems and alleviate your symptoms. We discussed the potential procedure, including an L5-S1 anterior lumbar interbody fusion and posterior spinal fusion, along with the removal and re-instrumentation of screws from L2 to S1. I will see you again before the surgery to go over the details and answer any questions you may have. Please continue to monitor your symptoms and let me know if they worsen.

Thank you for your trust in our care.

Sincerely,

[Doctor’s Name]

Structured Report

History of Present Illness

The patient, a 72-year-old woman, returns over a year after her previous surgery, experiencing worsened low back pain, groin pain, and pain down the left leg. She has had moderate left thigh numbness and pain since the surgery, which has been worsening. There are no bowel or bladder dysfunctions or symptoms of myelopathy.

General Exam

The patient’s incisions are well healed. She exhibits a grade 1 left hip flexor weakness but has intact strength and sensation in both upper and lower extremities. There is dense numbness in the left L3 distribution. Hips are non-irritable, and cranial nerves are grossly intact.

Physical Exam

  • Incisions: Well healed

  • Strength and Sensation: Intact in upper and lower extremities

  • Hip Flexor Weakness: Grade 1 on the left

  • Numbness: Dense in left L3 distribution

  • Hips: Non-irritable

  • Cranial Nerves: Grossly intact

Imaging Findings

  • CT Scan: Severe L1-2 degenerative disease, healed fusions at L2-3 and L3-4, solid fusion at L4-5, pseudarthrosis with loosened S1 screws at L5-S1.

  • MRI: Severe degenerative changes at L1-L2, large chronic superior T11 endplate Schmorl node, mild canal and moderate right foraminal stenosis at L1-L2, posterior disc bulge at T10-T11 causing moderate canal stenosis.

Treatment Plan

The plan involves noting any worsening pain. The proposed surgery includes an L5-S1 anterior lumbar interbody fusion and posterior spinal fusion, removal of screws from L2 to S1, and re-instrumentation from L4 to S1 with possible pelvic instrumentation. The patient is currently on cyclobenzaprine, sertraline, and Tylenol as needed.

Missing Items

  • Discussion of lifestyle modifications or physical therapy options.

  • Detailed explanation of non-surgical treatment alternatives.

  • Further investigation into the cause of the left thigh numbness beyond the lateral approach.

List of Medications

  • Cyclobenzaprine 10 mg p.o. t.i.d. for muscle spasm

  • Sertraline 50 mg p.o. q.d. for depression

  • Tylenol as needed

List of Orders

  • L5-S1 anterior lumbar interbody fusion

  • Posterior spinal fusion

  • Removal of screws from L2 to S1

  • Re-instrumentation from L4 to S1 with possible pelvic instrumentation