Add Clinical Logs

The Add Clinical Log page allows students to create detailed clinical experience logs with support for multiple patient encounters, AI-powered documentation, and comprehensive skill tracking.

Overview

Clinical logs document student experiences during clinical rotations. This page provides a flexible, template-driven form that supports:

• Multiple patient encounters per log
• Custom field templates defined by your classroom
• AI-powered voice transcription (AI Scribe)
• AI-generated SOAP notes
• Skill tracking with ability levels
• Time verification with location codes
• Draft saving and editing

Getting Started

Creating a New Clinical Log

1. Navigate to Clinical Logs from the main menu
2. Click "Add Clinical Log" button
3. The form will load with default values

Note: If you're coming from a completed shift, the form will be pre-populated with shift data including:

• Date and times
• Completed tasks converted to skills
• Classroom and location information

Required Information

Before submitting, you must provide:

• Class: Select the classroom for this clinical experience
• Preceptor: Select your assigned preceptor
• Date: Date of the clinical experience
• Start Time: Beginning time (or verify with code)
• End Time: Ending time (or verify with code)
• At least one patient encounter: Add at least one patient encounter

Form Structure

Header Section

The top card contains basic log information:

• Class: Required dropdown of available classrooms
• Preceptor: Required dropdown (populated based on selected class)
• Location: Optional location selection with search
• Date: Required date picker
• Start Time: Time input with optional verification
• End Time: Time input with optional verification
• Total Hours: Automatically calculated from start/end times

Time Verification:

• If your classroom has location verification enabled, you'll see verification buttons next to the time fields
• Click the key icon to enter a 4-digit verification code
• Verified times are locked and cannot be edited
• Verification codes are provided by your instructor

Patient Encounters

Each clinical log can contain multiple patient encounters. This allows you to document multiple patients seen during the same clinical session.

Adding Encounters

• Click "Add Encounter" button at the bottom of the form
• A new encounter card will appear
• Each encounter has its own set of fields and skills

Encounter Fields

Each encounter includes:

1. Template Fields: Custom fields defined by your classroom's clinical log template

   • Text fields
   • Number fields
   • Date fields
   • Textarea fields
   • Select dropdowns
   • Multi-select dropdowns
   • Searchable-select fields (for ICD-10 and CPT codes)

2. Skills: Patient-specific skills for this encounter

   • Select from template skills
   • Add custom skills (record-only, don't count toward requirements)
   • Track ability levels: Performed, Assisted, Observed
   • Enter counts for each ability level

3. AI SOAP Note Helper (if enabled):

   • Enter a brief summary
   • Click "Generate SOAP Note with AI" to create a formatted SOAP note
   • The generated note appears in the Notes field

4. Notes: Markdown-enabled notes field for detailed documentation

Deleting Encounters

• Click the trash icon in the encounter header
• Confirm deletion in the dialog
• The encounter will be removed from the log

AI Features

AI Scribe (Pro Plan Feature)

AI Scribe allows you to speak your clinical notes and have them automatically transcribed and structured.

How to Use:

1. Click the microphone icon on any patient encounter
2. Grant microphone permissions when prompted
3. Speak your clinical notes naturally
4. Click the stop button (or tap the floating button) when finished
5. The AI will process your speech and populate:
   • Patient demographics (from template fields)
   • Skills performed
   • ICD-10 and CPT codes (if applicable)
   • AI summary text
   • Suggested times and locations

Features:

• Real-time volume indicator while recording
• Automatic skill matching to template skills
• Fuzzy matching for skills not in template
• Code inference from spoken text
• Per-encounter recording (each encounter can be scribed separately)

Requirements:

• Institution must have Pro AI enabled
• Classroom must have student AI enabled
• Microphone access must be granted

AI SOAP Note Generation

Generate professional SOAP notes from brief summaries:

1. Enter a brief summary in the "AI SOAP Note Helper" field
2. Click "Generate SOAP Note with AI"
3. The AI creates a formatted SOAP note based on:
   • Your summary
   • Patient demographics
   • Skills performed
   • Clinical context

The generated note appears in the Notes field and can be edited as needed.

Skills Tracking

Template Skills

Skills are loaded from your classroom's skills template:

• Selecting Skills: Click "Select skills" to open the skills picker
• Search: Use the search box to find specific skills
• Select All: Quickly select all filtered skills
• Ability Levels: For each skill, track:
  • Performed: You performed this skill independently
  • Assisted: You performed this skill with assistance
  • Observed: You observed this skill being performed
• Counts: Enter the number of times for each ability level

Custom Skills

Add skills not in your template:

1. Scroll to the "Add Custom Skill" section in the encounter
2. Enter the skill name
3. Click "Add"
4. Track ability levels and counts as normal

Note: Custom skills are saved with your log but may not count toward skill progress requirements. Check with your program coordinator.

Per-Patient Skills

Skills can be tracked separately for each patient encounter:

• Each encounter maintains its own skill list
• Skills are aggregated when the log is saved
• This allows accurate tracking of skills per patient

Clinical Log Templates

Classrooms can have custom clinical log templates that define:

• Patient demographic fields
• Required vs. optional fields
• Field types (text, select, multi-select, etc.)
• ICD-10 and CPT code fields
• Custom field labels

Template Fields:

• Text: Single-line text input
• Number: Numeric input
• Date: Date picker
• Textarea: Multi-line text input
• Select: Single-choice dropdown
• Multi-select: Multiple-choice selection
• Searchable-select: Searchable dropdown (for ICD-10/CPT codes)

When you select a classroom, its template fields automatically appear in each patient encounter.

Medical Codes

ICD-10 Codes

Search and select ICD-10 diagnosis codes:

1. Find the ICD-10 field in your template (if present)
2. Type to search by code or description
3. Select codes from the dropdown
4. Selected codes appear as badges
5. Remove codes by clicking the × on each badge

CPT Codes

Search and select CPT procedure codes:

1. Find the CPT field in your template (if present)
2. Type to search by code or description
3. Select codes from the dropdown
4. Selected codes appear as badges
5. Remove codes by clicking the × on each badge

AI Code Inference: When using AI Scribe, codes may be automatically inferred from your spoken notes.

Saving and Submitting

Save as Draft

Click "Save as Draft" to:

• Save your progress without submitting
• Return later to complete the log
• Keep all entered data
• Continue editing

Auto-Save: When you verify start or end times, the log is automatically saved as a draft.

Submit Log

Click "Submit Log" to:

• Send the log to your preceptor for review
• Change status from "draft" to "pending"
• Lock the log (can only be edited if rejected)

Validation: Before submitting, the form checks:

• Required fields are filled
• At least one encounter is added
• Skills have at least one count entered
• Times are provided or verified

Editing Submitted Logs

• Pending/Resubmitted: Can be edited and resubmitted
• Approved: Cannot be edited (contact preceptor)
• Rejected: Can be edited and resubmitted with feedback addressed

Time Verification

Some classrooms require time verification using location codes:

1. Click the key icon next to Start Time or End Time
2. Enter the 4-digit verification code provided by your instructor
3. Click "Verify Code"
4. If correct:
   • The time is automatically set to the current time
   • The time field is locked (green background)
   • A verification badge appears
   • The log is auto-saved as a draft

Verification Requirements:

• End time can only be verified after start time is set
• Verified times cannot be edited
• Verification codes are classroom-specific

Shift Integration

If you're creating a log from a completed shift:

1. The form is pre-populated with:
   • Date and times from the shift
   • Completed tasks converted to skills
   • Classroom and location information
2. You can add additional encounters
3. Edit any pre-populated information
4. Submit or save as draft

Best Practices

1. Document Immediately: Create logs soon after clinical experiences while details are fresh
2. Use AI Scribe: Save time by speaking your notes instead of typing
3. Be Specific: Include detailed information in summaries and notes
4. Track Skills Accurately: Record the correct ability level and counts
5. Review Before Submit: Check all fields before submitting
6. Save Drafts: Use draft saving to work on logs over multiple sessions
7. HIPAA Compliance: Never include patient identifiers or protected health information
8. Use Templates: Follow your classroom's template structure for consistency

Troubleshooting

AI Scribe Not Available

• Check that your institution has Pro AI enabled
• Verify your classroom has student AI enabled
• Ensure microphone permissions are granted
• Try refreshing the page

Skills Not Loading

• Verify you've selected a classroom
• Check that the classroom has a skills template assigned
• Contact your administrator if skills are missing

Time Verification Not Working

• Ensure you're entering the correct 4-digit code
• Check that your classroom has verification enabled
• Verify the code hasn't expired
• Contact your instructor for a new code

Template Fields Missing

• Confirm your classroom has a clinical log template assigned
• Check that the template has fields defined
• Contact your administrator if fields are missing

Can't Submit Log

• Check for validation errors (red text under fields)
• Ensure all required fields are filled
• Verify at least one encounter is added
• Make sure skills have counts entered

Related Features

• Clinical Logs: View and manage all your clinical logs
• Review Logs: Preceptors review student logs here
• Skills Templates: Skills are defined in classroom templates
• Shifts: Complete shifts can be converted to clinical logs