Documentation Preferences.

Documentation Preferences are saved instructions that tell palmER how you like your notes written. Use them for the wording, content emphasis, level of detail, and formatting you would otherwise ask for each time.

Each document type has its own preferences: HPI, Exam, MDM, Discharge (DischargER patient documents), Critical Care, and Procedure. Instructions in one tab apply only to that document type.

For example, you might prefer a narrative HPI, a specific default exam format, or an MDM organized by sections with headings.

Documentation Preferences vs Follow-up Prompts

Choose based on how often you want an instruction applied:

• Documentation Preferences: Save a rule you want applied every time palmER writes that document type.
• Follow-up prompts: Ask for a change to the current note, such as Make this shorter or Expand the discussion of the disposition decision.
• Snippets: Save an instruction you reuse occasionally, then insert it when needed. Snippets can be thought of as a saved prompt.

The same instruction can work in all three places. Try Group the MDM under Assessment, Workup, and Disposition as a follow-up prompt. If you like it for every MDM, save it in the MDM preferences. If you only want it for certain cases, save it as a Snippet.

Getting Started

1. 01

   Open Documentation Preferences

   Open your user menu in palmER AI Suite and choose Documentation Preferences.

2. 02

   Choose a document type

   Select the HPI, Exam, MDM, Discharge, Critical Care, or Procedure tab.

3. 03

   Write and save

   Enter one or two instructions, then click Save. Save applies your changes across all six tabs, so you can edit several before saving.

For a simple starting point, try these in the MDM tab:

Use first-person active voice.
Keep straightforward cases concise.

Generate a note and review the result before adding more instructions.

Writing Effective Documentation Preferences

Write preferences as short, direct instructions. Describe the result you want and give an example when the wording matters.

Best Practices

1. Be specific. Instead of Improve the formatting, write Use all-caps section headings with a short paragraph under each heading.

2. Give exact wording when it matters. For example: Use "no acute distress" instead of "NAD".

3. Define templates clearly. Name the sections, put them in order, and specify whether each should contain a paragraph or bullets.

4. Make exclusions explicit. For example: Omit all billing statements such as "Medical decision-making was high complexity".

5. Keep each tab focused. Put exam terminology in Exam and patient-facing instructions in Discharge. Avoid pasting the same list into every tab.

6. Change one thing at a time. Test an instruction on a few notes before adding another. This makes it easier to tell which rule helped or caused a problem.

When to Use Follow-up Prompts

Use the message box for case-specific facts and one-time changes. Keep standing preferences focused on instructions you want to reuse.

• Condense the HPI into three sentences for the transfer summary.
• Rewrite without abbreviations.
• Expand the explanation of why the patient was admitted.

If you find yourself repeating the same request, decide whether it belongs in preferences or in a Snippet.

Example Preferences

Choose the examples that fit your style and adapt them. You do not need to use every example or paste an entire block into every tab.

General

These examples suit the MDM tab:

Always include HEART score for chest pain regardless of risk level.
Emphasize social determinants of health when relevant.
Include specific follow-up timelines (24-48 hours, etc.).
Troponin normal range < 57, Do NOT characterize as elevated when value < 57.
Always document patient understanding confirmation for high-risk discharges.

Clinical Decision Rules

These examples specify which clinical decision rules to include in the MDM:

Always include HEART score for chest pain patients.
Always include CHADS2-VASc score for atrial fibrillation patients.
Include CURB-65 for all pneumonia cases.
Include Ottawa ankle rules for all ankle injuries.

Billing and Complexity

Always OMIT the billing complexity statement; Do NOT document "Medical decision-making was high complexity..." or similar.
Emphasize data review elements that support complexity levels.
Document independent interpretation when performed.

Full MDM Template

If you prefer a consistent structure, save a template in the MDM tab:

Use these bold section headings in this order:

**Problems Addressed:** One bullet per problem with brief clinical reasoning.
**Data Reviewed:** Bullets grouped by labs, imaging, prior records, and discussions.
**Assessment & Plan:** One paragraph per problem, covering the assessment and plan together.
**Risk Stratification:** Explicit risk level (low / moderate / high) with one to two sentences of supporting rationale.
**Disposition:** The disposition decision, follow-up plan, and patient instructions.

Omit empty sections.
Omit billing statements such as "Medical decision-making was high complexity".

Assistant-Specific Tips

HPI Assistant

• Use for: Opening sentence, chronology, terminology, and level of detail
• Example wording rule: Use "reports" instead of "complains of"
• Example format rule: Start with the patient's age and chief complaint, then describe the history chronologically
• Use a follow-up prompt for: A shorter version of a specific HPI for a transfer summary

Physical Exam Assistant

• Use for: Preferred abbreviations, level of detail, exam components, bullet vs narrative, system groupings
• Example wording rule: Use "alert and oriented x3" instead of "AAOx3"
• Example format rule: Use one line per system, with the system name in ALL-CAPS
• Use a follow-up prompt for: A more abbreviated or expanded version of a specific exam

MDM Assistant

• Use for: Clinical documentation style, content emphasis, risk stratification, full section templates, paragraph vs bullet structure
• Example wording rule: Emphasize shared decision-making process details for complex cases
• Example format rule: Use these headings in order: Problems Addressed, Data Reviewed, Assessment & Plan, Risk Stratification, Disposition
• Use a follow-up prompt for: Expanding one part of the reasoning in a specific note

Discharge (DischargER)

• Use for: Institution name, tone, standard closing lines, default work or school note durations, reading level
• Example wording rule: Refer to our hospital as "Memorial General Emergency Department"
• Example format rule: Use separate headings for Medications, Follow-up, and When to Return, with bullet points under each
• Applies to: All patient documents written by DischargER. Specify the document when a rule should apply only to work notes, school notes, or discharge instructions.

Critical Care Notes

• Use for: Attestation wording, terminology, and paragraph structure
• Example wording rule: Use “I personally provided” in the critical care time statement
• Example format rule: Write one concise paragraph, with the total critical care time in a separate sentence at the end
• Applies to: Critical care notes written from a detection card in palmER Colab. Set the total critical care time on the card, not in preferences. See Critical Care and Procedure Detection.

Procedure Notes

• Use for: Procedure terminology, your usual anesthetic, section headings, your standard closing statements
• Example content rule: Document lidocaine 1% with epinephrine as my default local anesthetic
• Example format rule: Use these headings: Indication, Consent, Anesthesia, Technique, and Complications
• Applies to: Procedure notes written from a detection card in palmER Colab.

Testing Your Preferences

1. 01

   Save a small change

   Start with one or two instructions in the relevant tab and click Save.

2. 02

   Try a familiar case

   Generate a note for a case you know well so you can judge both the wording and the content.

3. 03

   Review the result

   Check that the note uses your preferred wording and structure, preserves the important details, and accurately reflects the encounter.

4. 04

   Refine and repeat

   If an instruction is ignored, make it more specific. Test across a few different cases before adding more rules.

Troubleshooting

"My formatting or template preferences aren't being followed"

• Check that you saved the instruction in the correct document tab.
• Give the exact headings, their order, and the format to use under each.
• Remove competing instructions and test the template on its own.

"Output is consistently unexpected or incorrect"

• Review the preferences for that document type, especially recent additions.
• Look for rules that contradict each other or ask for details that may not be available in every encounter.
• Copy your preferences somewhere safe, then clear that tab and save to compare the output without them.
• Add instructions back one at a time to identify the cause.

"Output is too long or too short"

• Make length guidance conditional: Keep straightforward cases concise; use more detail for complex cases.
• Name the section to shorten or expand rather than changing the length of the entire note.
• For a one-time adjustment, use a follow-up prompt instead of changing your saved preferences.

Quick Start

Choose one document type, save one or two preferences, and try them on a familiar case. Build from the changes that work. Keep a copy of your preferred instructions before making larger revisions.