What are the 10 clinical-note fields, and how are they filled?
Last updated: 2026-05-26
Every voice clinical note is auto-structured into 10 fields: Chief Complaint, History of Present Illness, Medical History, Observation, Investigation, Diagnosis, Treatment Plan, Treatment, Cost, and Notes. The AI fills only what you said — empty fields stay empty rather than being invented.
The 10 fields
| Field | What it captures |
|---|---|
| Chief Complaint | What the patient came in with, in their words. |
| History of Present Illness | Onset, duration, triggers, what has been tried. |
| Medical History | Relevant conditions, prior treatments, family history. |
| Observation | What you saw on exam — intra-oral findings, mobility, swelling, etc. |
| Investigation | X-rays ordered, vitality tests, lab work. |
| Diagnosis | Your clinical impression. |
| Treatment Plan | What you intend to do, in what order. |
| Treatment | What you actually did today. |
| Cost | Fee for today’s work and/or full plan estimate. |
| Notes | Anything else — patient instructions, follow-up rationale, internal reminders. |
How fields get filled
When you dictate the consultation, the AI listens for cues that match each field — "patient complains of pain on tooth 36" → Chief Complaint; "I am seeing decay on the distal" → Observation; "we will need a root canal followed by a crown" → Treatment Plan.
You do not need to announce the fields. Just speak naturally. If you do not mention something, the field stays empty — the AI will not invent content.
Editing fields
Each field accepts free text up to roughly 2,000 characters. Click into any field to add or correct. Edits update the record without changing the visit’s position on the timeline.
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