i-scribe writes your notes and letters from what is said during the consult. Anything that is implied, such as a gesture, shorthand, or a finding you see but don't name, can be missed or interpreted incorrectly.

```callout kind="success"
**The most effective habit:** before you generate, summarise the diagnosis and plan out loud, including the side.

"Just to summarise, the diagnosis is left middle ear effusion. The plan is a CT scan of the temporal bones, then a left grommet and left Eustachian tube balloon dilation."
```

## 1. Summarise the diagnosis and plan out loud

A short spoken summary at the end of the consult gives i-scribe one clear, explicit source for the most important parts of your note or letter. Without it, the diagnosis and plan may be ordered differently from how you'd like, worded less precisely, or based on assumptions where details weren't said explicitly.

A good summary:

- **Names the diagnosis** in the wording you want in the letter.
- **States the side** for every finding and procedure.
- **Lists the plan in order**, including investigations, procedures and follow-up.

You can also number items as you go:

> "Your diagnoses are: one, osteoarthritis of the right knee. Two, hypertension. Three, type 2 diabetes. The plan is: one, a right knee X-ray. Two, physiotherapy referral. Three, review in six weeks."

This helps i-scribe keep your wording, list items in your order, and capture the correct side.

## 2. Always name the side

Laterality is the detail most likely to go wrong if it is implied. This often happens when the patient describes a symptom on one side but your finding is on the other, or when you say "this one" or "the other one" instead of naming the side. Say the side out loud for findings, diagnoses and procedures. Some examples:

**Examination findings**

- Instead of: "One ear has no fluid, the other has a lot."
- Say: "The right ear is clear. The left ear has a middle ear effusion."

**When the patient gestures**

- Instead of: saying nothing when the patient points to their knee
- Say: "Just to clarify, that is the right knee."

**The plan**

- Instead of: "We'll put a grommet in."
- Say: "The plan is a left grommet."

```callout kind="warning"
If the patient mentions symptoms on a different side from your finding, state your finding and the side clearly so the two aren't confused.
```

## 3. Choose when to clarify

You can clarify details and give your summary in front of the patient or after they leave.

**With the patient.** After consenting the patient for i-scribe, you can let them know you'll be speaking some details aloud. For example:

> "Since my computer is writing my notes for me, you'll hear me say some details out loud. Let me know if you have any questions."

Summarising the diagnosis and plan to the patient also helps them understand what happens next.

**After the patient leaves.** Keep the recording running once the patient has left, then dictate your summary of the examination, diagnosis and plan before you generate.

```callout kind="info"
If you regularly dictate your examination and plan at the end of the consult, add a **Dictaphone Mode - Smart** or **Dictaphone Mode - Verbatim** output alongside your letter. These capture dictated content more closely.
```

## Related articles

- [Dictaphone Mode vs. Conversation Mode](https://help.akuru.com/i-scribe/dictaphone-mode-vs.-conversation-mode)
- [How to flag an output](https://help.akuru.com/i-scribe/how-to-flag-an-output)