A Practical Guide to Outlining Your AI Charting Templates

AI charting is only effective when it captures what matters to your practice. While the technology can improve documentation speed, its practical value depends on how well it aligns with your clinical workflow and documentation standards.

This guide helps you define your clinical needs without getting technical. You'll focus on what you need documented, leaving the technical implementation to AI platforms that handle the complexity for you. The goal is to make your AI-generated notes sound like they came from a real provider.

Step 1: Make a Plan

Before addressing specific requirements, establish a clear implementation strategy. Your plan should address three key decisions that will shape everything that follows.

Identify which templates need AI support. Start with the documentation that consumes the most time or causes the most friction in your workflow. For most practices, this means E&M visits and psychotherapy notes. Consider your implementation approach—are you maintaining current note structures, optimizing strategically, or transforming comprehensively? Your choice here determines how much flexibility you have in defining AI summaries.

See our article on implementation approaches here

Decide on standardization versus provider flexibility. Group practices face a common challenge: balancing consistency across providers with individual documentation styles. Some practices benefit from fully standardized notes that support uniform quality and compliance. Others find that allowing provider-specific variations improves adoption and satisfaction. Many practices choose a hybrid approach—standardizing certain sections like medication lists while allowing flexibility in assessment narratives.

Map templates to existing EHR fields. Your AI summaries need somewhere to land in your electronic health record. Review your current EHR setup and identify which text fields will receive AI-generated content. If you're maintaining current structures, you'll work within existing fields. If you're optimizing, you might consolidate multiple fields into broader text areas that allow AI to work more efficiently.

Step 2: Define What You Need

For each template type, create two lists. The inclusion list covers elements that must appear in every note: presenting concerns, medication changes, safety assessments, and treatment plan updates. The exclusion list matters too—perhaps you don't want verbatim patient quotes in certain sections, or you prefer to handle sensitive topics like substance use in separate fields.

Your notes should maintain the professional voice your practice has developed over time. Consider whether you prefer narrative paragraphs that flow like traditional psychiatric notes or structured bullets that make specific information easier to locate. Think about tense (past vs. present), perspective (first-person clinical observations vs. third-person reporting), and level of detail for different note sections. Platforms like Kenzie excel at translating these preferences into consistent documentation without requiring technical knowledge from you.

Nothing communicates your requirements better than actual notes that show your standards. Pull 3-5 examples of well-written notes for each template type. These samples help the AI learn your specific approach—whether that's your particular way of documenting medication rationale, your format for capturing therapy interventions, or your style of summarizing mental status exams. A good implementation partner will use these examples to configure the AI to match your clinical voice.

Step 3: Test Your Definitions

Test with the full complexity of actual appointments—not just straightforward medication checks, but challenging cases with multiple concerns, medication changes, and psychosocial stressors. Include scenarios that push the boundaries of your definitions: crisis situations, initial evaluations, complex medication adjustments, and family sessions. At Kenzie, we test your summaries in a dedicated environment before you ever use them in a real appointment. This helps you always have the best experience in your sessions.

Check systematically against your inclusion lists. Does every required element appear? Is critical information like suicide risk assessment always documented? Are medication changes recorded with appropriate detail? Pay special attention to compliance requirements and billing documentation needs.

Beyond accuracy, your AI-generated notes should feel right. They should reflect the professionalism and clinical thoughtfulness that your patients expect. The language should match how you actually speak about clinical observations.

Step 4: Keep Improving Your Templates

Documentation needs to evolve as your practice grows and clinical standards change. The most successful AI implementations build in continuous improvement from the start.

Create a simple system for providers to flag issues or suggest improvements. This might be as straightforward as a shared document where providers note recurring problems or desired changes. Good AI platforms actively monitor this feedback and refine templates accordingly. At Kenzie, we treat implementation as an ongoing partnership rather than a one-time setup.

Watch for signs that your templates need updating: providers consistently editing the same sections, new documentation requirements from insurers, changes in clinical focus areas, or feedback that notes don't capture important nuances. Regular check-ins—perhaps quarterly—help catch these needs before they become frustrations.

If you have multiple clinicians, monitor how different providers interact with the AI summaries. You might discover that certain providers have developed particularly effective documentation patterns that could benefit the entire practice. This collaborative refinement keeps your AI documentation improving over time.

Real-World Examples

Here's what this looks like in practice:

Summary	Must Include	Style Preferences	Exclude
E&M Visit Summary Requirements	Chief complaint and duration of symptoms Pertinent history since last visit Current medication list with doses Medication effectiveness and side effects discussed Safety assessment (SI/HI/psychosis) Diagnosis updates or confirmations Treatment plan changes Next appointment timing and rationale	Narrative format for history and assessment Bulleted list for medications Present tense for mental status exam Clear section breaks between major components	Detailed psychotherapy content (document separately) Verbatim patient quotes about other providers Speculative diagnoses not yet discussed with patient
Psychotherapy Note Requirements	Session focus and primary themes Interventions used (CBT techniques, mindfulness exercises, etc.) Patient response to interventions Homework assigned or reviewed Progress toward treatment goals Any safety concerns addressed Plan for next session	Narrative paragraphs Focus on clinical observations, not session play-by-play Professional but warm tone Past tense throughout	Excessive personal details about third parties Specific quotes that could be taken out of context Information better suited to E&M documentation

These examples demonstrate the level of detail needed without getting into technical implementation. Your actual requirements will reflect your practice's unique needs and standards.

Conclusion

An effective charting assistant will help turn your clinical expertise into accurate, reliable, and comprehensive notes. By focusing on what you need documented rather than how the technology works, you create a foundation for AI assistance that improves your practice.

The key is finding an AI platform that partners with you throughout this process. Strong solutions handle the technical complexity while respecting your clinical expertise, so your AI-generated documentation supports your professional voice.

Your definitions will evolve as you work with AI documentation. Start with clear requirements, test thoroughly, and refine based on real-world use. With the right approach and partnership, AI charting becomes a natural extension of your clinical practice.