Guide
Document patient visits efficiently with structured notes, AI-powered dictation, and automated data extraction.
Open a clinical session to create a complete, timestamped record of the patient encounter.
Find the patient from your appointment list or search by name, phone number, or patient ID. Click on the patient to open their record, then select Start Session or click on their scheduled appointment to begin.
Select the encounter type — initial consultation, follow-up, emergency, or procedure. This determines the default note template and any required fields. Cari pre-populates relevant information from the patient's last visit, including active medications, pending lab results, and outstanding action items.
Before you begin documenting, Cari displays a clinical summary panel showing active problems, allergies (highlighted in red if severe), recent vitals trends, and current medications. This takes seconds to scan and ensures you have full context before the consultation starts.
The clinical summary panel is always visible in the sidebar during a session. You can collapse it for more screen space, but reviewing it at the start of each encounter prevents missed information.
Use the industry-standard Subjective, Objective, Assessment, and Plan framework for consistent documentation.
Subjective
Chief complaint, history of present illness, review of systems
Objective
Physical exam findings, vitals, lab results
Assessment
Working diagnosis, differential diagnoses, ICD-10 codes
Plan
Medications, investigations, referrals, follow-up
Document the patient's chief complaint, history of present illness, and review of systems in their own words. Record symptom onset, duration, severity, and any aggravating or relieving factors. Cari provides structured symptom selectors alongside free-text entry for speed.
Record physical examination findings and vital signs. Enter blood pressure, heart rate, temperature, respiratory rate, oxygen saturation, weight, and height. Cari automatically calculates BMI and flags abnormal values based on age and gender norms. Examination findings can be entered as free text or using body-system checklists.
Enter your clinical assessment — the working diagnosis or differential diagnoses. Search for ICD-10 codes by keyword and select the most appropriate code. Cari's AI-powered diagnosis assistant can suggest likely diagnoses based on the symptoms and findings you have documented, ranked by probability.
Document the treatment plan: medications prescribed, investigations ordered, referrals made, and follow-up instructions. Each element creates structured entries — a prescription generates a dispensing order, a lab request appears in the lab queue, and a follow-up creates a scheduling prompt.
All prescriptions entered in the Plan section are automatically checked for drug-drug interactions and drug-allergy conflicts before they can be finalized. Never bypass these safety alerts.
Speak naturally and let AI extract clinical entities from your dictation in real time.
Click the microphone icon in the session toolbar to start recording. Cari uses on-device speech recognition where available and falls back to cloud transcription. The transcript appears in real time as you speak.
Describe the encounter as you normally would — "The patient presents with a three-day history of cough and fever. Temperature 38.5. I'm prescribing amoxicillin 500mg three times daily for seven days." Cari transcribes your speech and simultaneously identifies clinical entities: symptoms, vitals, diagnoses, medications, and dosages.
Voice dictation works best in a quiet environment. If your clinic is noisy, use a headset with a directional microphone for better accuracy.
Click the microphone icon again to stop. Cari processes the full transcript and highlights all extracted entities for your review. You can also add manual entries alongside dictated content.
Verify AI-extracted entities before they are committed to the patient record.
After dictation, Cari displays a review panel with categorised extractions: vitals, symptoms, diagnoses (with suggested ICD-10 codes), medications (with dosage and frequency), and action items. Each entity is editable — click to modify, remove, or reclassify.
Check the items you want to commit to the patient record and uncheck any that are incorrect. You can also add items that the AI missed. This human-in-the-loop step ensures that the structured data in the EHR is always clinician-verified.
AI extraction saves time, but clinical accuracy requires human verification. Cari never commits extracted data to the patient record without your explicit approval.
Click Commit to write the approved entities into the patient's clinical record. Vitals are added to the vitals chart, diagnoses to the problem list, and prescriptions to the medication orders. The raw transcript is preserved as an audit trail.
You can also add vitals, diagnoses, and prescriptions manually at any point during the session without using voice dictation — use the Add Vitals, Add Diagnosis, and Add Prescription buttons in the session toolbar.