Ambient Clinical Documentation
How to instruct Copilot during and after patient encounters for accurate ambient notes.
Microsoft Cloud Partner Training Material
Microsoft Dragon® Copilot
AI Prompt Mastery
Complete training guide for clinicians: from ambient documentation to "Prepare My Note" automation. Open in any browser, fully interactive.
Ambient AI Templates In-Note Commands
Summarization Prepare My Note Practice Lab
Your Complete Training Path
Dragon Medical Copilot uses generative AI: not transcription. How a doctor phrases a prompt fundamentally changes the output. This training teaches clinicians to write prompts that are specific, contextual, and format-aware.
Custom Instructions & Templates
Designing specialty-specific note prompts that produce consistent, structured output.
In-Note Commands
Voice commands for editing, formatting, inserting, and correcting within a draft note.
Summarization & Follow-Up
Prompts for patient summaries, referral letters, portal messages, and discharge notes.
Prepare My Note Prompts
ICD-10, CPT, eCW, billing, and safety flag prompts that run automatically after every note.
- 1
Dragon Copilot is generative, not transcriptive
Unlike older Dragon versions that transcribed every word, Copilot interprets and structures content. What the doctor says, and how, determines what gets written.
- 2
Context commands shape the whole note
Instructions like "Document this as a SOAP note for cardiology" before speaking will change the output structure entirely.
- 3
Specificity reduces editing time
Prompts that include format, tone, audience, and required sections dramatically cut post-generation review time.
- 4
Doctors can teach the AI their preferences
Custom instructions saved in templates allow Copilot to "remember" how each physician likes their notes formatted.
- 5
"Prepare My Note" runs automatically
Post-note prompts execute after every note: adding codes, flagging safety issues, and formatting for the EHR without any extra physician action.
Ambient Clinical Documentation
Ambient AI captures the natural conversation between doctor and patient and converts it into a structured clinical note. The prompt spoken before or after the encounter frames how Copilot interprets and documents that conversation.
Key principle: Always state the note type, specialty context, and any required sections before the encounter begins. This primes Copilot's output structure.
Note type+Specialty / context+Required sections+Tone / audience
More elements = more precise output. Even 2-3 elements significantly improves the note.
Ambient AI: Beginner
A primary care physician about to see a routine visit patient:
"Dragon, start ambient documentation. This is a primary care follow-up visit. Please use SOAP format."
Why it works: States note type (follow-up), specialty (primary care), and format (SOAP). Copilot organizes Subjective, Objective, Assessment, and Plan automatically.
Ambient AI: Intermediate
A cardiologist seeing a patient for chest pain evaluation:
"Begin ambient note. Cardiology new patient visit. Include sections for cardiac history, risk factors, current medications, exam findings, and assessment with differential. Flag any medications I mention that are cardiovascular drugs."
Why it works: Specialty-specific sections are named explicitly. The flag instruction prompts Copilot to highlight drug categories, saving a review step later.
Ambient AI: Advanced
A psychiatrist conducting a 60-minute intake session:
"Ambient documentation, psychiatric intake. Structure as: Chief Complaint, HPI, Psychiatric History, Family History, Social History, Mental Status Exam, DSM-5 working diagnosis, and Treatment Plan. Do not include exact quotes from the patient. Use clinical language. Flag any mention of suicidal ideation or harm."
Why it works: Adds a critical safeguard, mandates clinical language, and builds in a safety flag supporting risk documentation workflows.
Do This, Not That
Weak prompt
"Document my visit."
No structure guidance. Output will be a flat paragraph, harder to review and less EHR-ready.
Strong prompt
"Document this orthopedic follow-up as a progress note. Include pain score, ROM findings, imaging review, and updated treatment plan."
Produces a structured, section-labeled note that slots directly into the EHR.
Remind clinicians: Always review AI-generated notes before signing.
Custom Instructions & Templates
Specialty-specific templates let clinicians set recurring preferences once, then reuse them for consistent structured notes.
Template: Primary Care Follow-Up
"Always document my visits as follows:
- Visit type: [new patient / follow-up / annual wellness]
• Sections required: Reason for visit, HPI, Current medications (with doses), Allergies, Vitals, Physical exam findings, Assessment, Plan with numbered action items
• Tone: Formal clinical language, third person
• Chronic conditions: Always list active problems at the top
• Abbreviations: Use standard medical abbreviations (HTN, DM2, CAD, etc.)"
- Visit type: [new patient / follow-up / annual wellness]
• Sections required: Reason for visit, HPI, Current medications (with doses), Allergies, Vitals, Physical exam findings, Assessment, Plan with numbered action items
• Tone: Formal clinical language, third person
• Chronic conditions: Always list active problems at the top
• Abbreviations: Use standard medical abbreviations (HTN, DM2, CAD, etc.)"
Why it works: Set once, applies to every visit. The physician never has to re-explain preferences.
Template: Cardiology Consultation
"For all cardiology consultations:
- Sections: Reason for Consult, Cardiac History, CV Risk Factors, Current Cardiac Meds, Relevant Labs, Echo/Stress Test results if mentioned, Physical Exam (cardiac and vascular), EKG findings, Impression and Recommendations
• Medications: Always list with dose, frequency, and indication
• Highlight: Any new findings that differ from prior studies
• Close with: Clear recommendation paragraph addressed to the referring physician"
- Sections: Reason for Consult, Cardiac History, CV Risk Factors, Current Cardiac Meds, Relevant Labs, Echo/Stress Test results if mentioned, Physical Exam (cardiac and vascular), EKG findings, Impression and Recommendations
• Medications: Always list with dose, frequency, and indication
• Highlight: Any new findings that differ from prior studies
• Close with: Clear recommendation paragraph addressed to the referring physician"
Why it works: The closing recommendation paragraph for the referring physician eliminates a common documentation friction point in cardiology.
Template: Orthopedics Post-Op Follow-Up
"Post-operative follow-up note structure:
- Header: Procedure performed, date of surgery, weeks post-op
• Sections: Patient-reported pain score (0-10), Current ROM measurements, Wound/incision status, Weight-bearing status, PT progress, Imaging review, Assessment, Updated plan
• Physical therapy: Note current phase of rehab protocol
• Return to activity: Always include projected timeline if discussed"
- Header: Procedure performed, date of surgery, weeks post-op
• Sections: Patient-reported pain score (0-10), Current ROM measurements, Wound/incision status, Weight-bearing status, PT progress, Imaging review, Assessment, Updated plan
• Physical therapy: Note current phase of rehab protocol
• Return to activity: Always include projected timeline if discussed"
Why it works: ROM measurements, pain scores, and weight-bearing status are orthopedic-specific data points that Copilot will specifically capture from the conversation.
Template: Psychiatry Medication Management
"Psychiatric medication management note:
- Sections: Interval History, Current symptoms (mood, sleep, appetite, energy, concentration), Side effects, Current medications with doses, MSE summary, Safety assessment, Medication changes, Psychotherapy status, Return plan
• Safety: Always include a dedicated safety assessment line, even if patient denies SI/HI
• Language: Avoid direct quotes. Use clinical paraphrase.
• Coding support: Note visit complexity (low/moderate/high)"
- Sections: Interval History, Current symptoms (mood, sleep, appetite, energy, concentration), Side effects, Current medications with doses, MSE summary, Safety assessment, Medication changes, Psychotherapy status, Return plan
• Safety: Always include a dedicated safety assessment line, even if patient denies SI/HI
• Language: Avoid direct quotes. Use clinical paraphrase.
• Coding support: Note visit complexity (low/moderate/high)"
Why it works: The explicit safety documentation protects the physician medico-legally. Coding complexity tagging supports billing accuracy.
Template: Pediatrics Well Child Visit
"Well child visit note: all ages:
- Sections: Age, Weight/Height/Head Circumference (with percentiles), Developmental milestones, Nutrition and feeding, Sleep, Safety counseling, Immunizations given today, Vision/Hearing screens, Physical exam by system, Assessment and anticipatory guidance
• Growth: Flag if any measurement falls below 5th or above 95th percentile
• Anticipatory guidance: List as bullet points
• Next visit: Recommended age for next well child exam"
- Sections: Age, Weight/Height/Head Circumference (with percentiles), Developmental milestones, Nutrition and feeding, Sleep, Safety counseling, Immunizations given today, Vision/Hearing screens, Physical exam by system, Assessment and anticipatory guidance
• Growth: Flag if any measurement falls below 5th or above 95th percentile
• Anticipatory guidance: List as bullet points
• Next visit: Recommended age for next well child exam"
Why it works: Percentile flagging and anticipatory guidance bullets are pediatrics-specific: this template would take 25+ minutes to write manually per patient.
Template: Rheumatology Visit
"For all rheumatology visits, always include:
- Sections: Joint involvement (specify joints), Disease activity score, Current biologics (with start dates), Current DMARDs, Relevant labs (ESR, CRP, ANA, RF, anti-CCP), Flare assessment, Physical exam, Assessment, Plan
• Biologics: Always note date of last infusion or injection
• Flare: If documented, note trigger and management response
• Labs: Flag any ESR or CRP above normal range"
- Sections: Joint involvement (specify joints), Disease activity score, Current biologics (with start dates), Current DMARDs, Relevant labs (ESR, CRP, ANA, RF, anti-CCP), Flare assessment, Physical exam, Assessment, Plan
• Biologics: Always note date of last infusion or injection
• Flare: If documented, note trigger and management response
• Labs: Flag any ESR or CRP above normal range"
Why it works: Disease activity scores and biologic dates are recurring rheumatology documentation requirements. Naming them explicitly ensures Copilot captures them from every conversation.
In-Note Voice Commands
Once a note draft is generated, clinicians can edit, reformat, add, and correct using natural language voice commands without touching a keyboard.
Key principle: In-note commands work best when they reference specific sections by name. "Fix the plan section" outperforms "fix this."
| Action | Command Example | Tips |
|---|---|---|
| Add a section | "Add a section called Allergies after the medications section" | Name the new section and anchor it to an existing one. |
| Delete content | "Remove the sentence about ibuprofen in the Plan" | Specify which section to avoid deleting the wrong content. |
| Condense a section | "Condense the Assessment into one concise paragraph with the primary diagnosis first" | Name the target section and the exact length or structure. |
| Replace terminology | "Replace hypertension with HTN throughout the note" | Use global replace language when the change should apply everywhere. |
| Reformat | "Convert the Plan section into a numbered list of action items" | State the destination section and the desired format. |
| Change tone | "Rewrite the patient instructions at a 6th grade reading level with no abbreviations" | Always specify the audience and reading level. |
| Move content | "Move the imaging review sentence from HPI to Objective" | Identify the source and destination sections. |
| Add a safety item | "Add a medication safety note at the top if any interactions are mentioned" | Make safety flags visible and labeled. |
| Create follow-up | "Draft a portal message under 150 words summarizing the lab results" | Add length, audience, and purpose. |
| Finalize | "Add Billing Documentation at the end with MDM level and suggested E/M code" | Use a consistent label so reviewers can find it quickly. |
Summarization & Follow-Up Generation
Beyond the visit note, Dragon Copilot can generate patient summaries, referral letters, after-visit instructions, and follow-up messages from a single prompt.
Key principle: Always specify the audience and purpose. A referral letter for a specialist reads very differently from a patient-facing discharge summary.
Patient-facing summary
After completing a diabetes management visit:
"Generate a patient-friendly after-visit summary from today's note. Use plain language (6th grade reading level). Include: what we discussed, medication changes, and three things the patient should do before the next appointment. No medical abbreviations."
Why it works: Reading level instruction and action-item format make this directly usable for the patient portal without physician editing.
Referral letter
Referring a patient to a gastroenterologist:
"Write a formal referral letter to gastroenterology based on today's visit. Address it to Dear Colleague. Include: reason for referral, relevant GI history, current medications, recent labs (CBC, CMP, CRP), and my specific clinical question. Close with my contact information placeholder."
Why it works: The "clinical question" instruction ensures the referral has a clear ask, which most specialists require for triage.
Portal message
Explaining lab results through the patient portal:
"Draft a secure message to the patient explaining their lab results from today. Keep it under 150 words. Separate normal results from abnormal results. Include the next step, when to call the office, and avoid medical abbreviations."
Why it works: A word limit, audience, and action step make the message usable without rewriting.
Discharge instructions
Preparing follow-up instructions after discharge:
"Generate patient-friendly discharge instructions from today's note. Use plain language. Include medication changes, red flag symptoms, follow-up timing, and who to call with questions."
Why it works: It separates clinical documentation from patient-facing instructions and gives the patient clear next steps.
Prepare My Note Prompts
Prepare My Note prompts run automatically after a note is generated. They can add codes, flag safety issues, format for the EHR, and prepare billing support before physician review.
1
Encounter captured
Conversation becomes the source material
2
Draft generated
Copilot creates the clinical note
3
Prompt runs
"Prepare My Note" instructions execute automatically
4
Note delivered
Physician reviews fully prepared note
From a real physician's setup: The prompts below reflect actual "Prepare My Note" configurations in use. The key technique, silent omission, keeps the note clean when no code is found.
ICD-10: Standard
"Look up the ICD-10 codes for each of the diagnoses mentioned during the visit and include them in parentheses beside the diagnosis. If no code is found, do not report that there is no code found. In that case, do not include the parentheses at all."
Why it works: The silent omission instruction is critical. Without it, Copilot writes "(No code found)" next to uncertain diagnoses, cluttering the note and creating documentation liability.
CPT-2: Standard
"Look up the CPT 2 codes for any procedures mentioned during the visit and include them in parentheses beside the procedure. If no code is found, do not report that there is no code found. In that case, do not include the parentheses at all."
Why it works: Same silent omission logic for procedures. It keeps the note clean even when exotic or unlisted procedures are discussed.
ICD-10: High Specificity
"Look up the most specific ICD-10 code available for each diagnosis mentioned during the visit. Include the code in parentheses immediately after the diagnosis name. Use the highest specificity code available, such as laterality, acuity, and episode. If no code is found, omit the parentheses entirely."
Why it works: Specificity prompts encourage laterality, acuity, and episode detail instead of generic coding suggestions.
eCW Formatting
"Format this note for use in eClinicalWorks. Use clear section labels, keep the plan as numbered action items, and place diagnosis codes beside each diagnosis when available."
Why it works: eCW-specific formatting reduces cleanup before the note moves into the chart.
Referral Summary
"If any referrals were mentioned during the visit, add a Referral Summary section at the end with specialty, reason in one sentence, urgency (routine/urgent/emergent), and relevant ICD-10 codes."
Why it works: The referral block gives staff a clean handoff with specialty, reason, urgency, and codes in one place.
Primary Diagnosis Label
"If multiple diagnoses are listed, label the primary diagnosis with [PRIMARY] before the ICD-10 code and keep secondary diagnoses listed below it."
Why it works: The primary diagnosis label supports chart review and billing workflows without adding clutter.
Billing & E/M
"At the end of the note, add a brief Medical Decision Making (MDM) summary labeled "Billing Documentation." Include: number of problems addressed, data reviewed, risk level (low/moderate/high), and suggested E/M code (99211-99215 established, 99201-99205 new)."
Why it works: This auto-captures the breakdown when the physician mentions total time or MDM elements.
Denial Prevention Flags
"Flag any missing billing requirements: (1) Medical necessity statement for procedures, (2) Signature placeholder, (3) Date of service, (4) Ordering physician name if referral placed, (5) Modifier justification for bilateral/repeated procedures. List under: Billing Review Needed."
Why it works: These are common sources of first-pass claim denials. Auto-checking catches issues before they reach the billing team.
Key principle: Safety prompts should generate visible, labeled flags. A physician scanning a note should see the alert immediately, and the section's presence is the alert signal.
Medication Safety
"Review all medications: existing and newly prescribed. If any concerns, add MEDICATION SAFETY REVIEW at the top: (1) Major drug-drug interactions, (2) Contraindications with diagnoses, (3) Doses outside standard adult ranges. If no flags apply, do not include this section."
Why it works: The "omit if clear" instruction trains physicians to treat the section's presence as the alert. A clean note means no issues were flagged.
Behavioral Health Safety
"If safety concerns were assessed, add SAFETY ASSESSMENT section after the HPI: what was asked, patient response, clinician judgment. If safety was not assessed but the visit type warrants it, add: [SAFETY ASSESSMENT: To be completed before signing]."
Why it works: The placeholder creates a mandatory documentation reminder. Medico-legally, an unsigned safety assessment placeholder is better than a missing one.
Critical Values Alert
"Review any lab values, vitals, or diagnostic results. If any fall outside normal ranges, add CLINICAL ALERT at the very top: the abnormal value, normal range, and whether a physician response is documented. If all values are normal, omit this section entirely."
Why it works: Critical value documentation depends on showing the abnormal value and physician response. The prompt makes that review visible before signing.
Include in prompt:
Generated Prompt
Select your options above.
Copied!Quick Reference Cheat Sheet
Use these as fast reminders during clinician training sessions.
| Prompt Skill | Weak | Better |
|---|---|---|
| State the role | Write my note | "Document this as a cardiology new patient consultation" |
| Set the length | Be concise | "Limit the summary to 3 sentences" |
| List required sections | Include everything important | "Include: HPI, exam, assessment, plan" |
| Add flags | Note anything unusual | "Flag any new medications or abnormal values" |
| Specify tone | Sound professional | "Formal clinical language, third person" |
| Anchor edits | Fix that part | "In the Plan section, change the follow-up interval to 4 weeks" |
| Silent omission | Add codes if you find them | "If no code is found, omit the parentheses entirely" |
"Use SOAP format""Third person, formal""6th grade reading level""No abbreviations""Flag new medications""Numbered action items""Under 150 words""Address to referring physician""Highlight changes from last visit""Positive findings first""Include ICD-10 suggestion""Add safety assessment line""If no code found, omit silently""Label primary diagnosis [PRIMARY]""Format for eCW""Billing Documentation section"
Practice Lab
Scenario-based exercises for clinician training sessions. Write a prompt for each scenario, then check your answer.
Exercise 1 of 5: Ambient Documentation
The Unprepared Internist
Scenario: Dr. Chen is an internist seeing a 64-year-old for a follow-up on hypertension and type 2 diabetes. She wants a note with vitals, medication review, labs discussed, assessment, and a numbered plan.
Your task: Write the ambient documentation prompt she should say before the encounter starts.
Exercise 2 of 5: Custom Template
The Rheumatologist's Template
Scenario: Dr. Okonkwo is a rheumatologist who sees patients for RA, lupus, and gout. She wants a saved template that always includes: joint involvement, disease activity score, current biologics with dates, labs (ESR, CRP, ANA), and a flare assessment.
Your task: Write the custom instruction template she should save in Copilot.
Exercise 3 of 5: In-Note Command
The Messy Assessment
Scenario: Copilot generated a 5-paragraph Assessment section. Dr. Patel needs it condensed to one concise paragraph, with the primary diagnosis listed first, and he wants "hypertension" changed to "HTN" throughout the note.
Your task: Write the in-note voice command to accomplish all three edits.
Exercise 4 of 5: Prepare My Note
The Coding Setup
Scenario: Dr. Williams wants to configure a "Prepare My Note" prompt for her primary care practice using eClinicalWorks. She wants ICD-10 codes added silently, a referral block if referrals were mentioned, and a medication safety flag if any issues are found.
Your task: Write the complete "Prepare My Note" prompt for her eCW setup.
Exercise 5 of 5: Advanced Chain
The Complete Workflow
Scenario: Dr. Kim is a hospitalist. She needs to: (1) add a discharge summary section, (2) flag medications changed during admission, (3) generate patient-friendly discharge instructions, and (4) draft a follow-up letter to the patient's PCP.
Your task: Write a sequence of prompts to accomplish all four tasks.
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