MT
Margaret Thompson
Active
AI Summary
SUMMARY OF VISIT
Reason for visitPatient having fever & cough for last 3 days, DM2 + HTN follow-up
Summary of patientRecently diagnosed with Hypertension & Diabetes. Fatigue ongoing for 8 weeks. Inconsistent medication adherence noted.
SDOHLives alone, job stress flagged, food secure, transportation available
LifestyleWalks ~1,000 steps/day, practices medication as instructed intermittently
Relationship3 years with us, active subscriber on $99 plan, has 4 family members enrolled
Last contact3 days ago (Ela AI Call)
EducationDM2 done, HTN pending
Active goalsWalk 10,000 stepsBP <130/80 ✓HbA1c <7.5 ✗
Assessment scorePHQ-9 (11), GAD-7 (8)
VitalsSpO2 98%, Height 176cm, Weight 100kg, BMI 32.4
Behavioural insightsAverage sleep 5 hrs, follows mostly plant-based diet
Life insightsSoftware engineer with 2 kids, wants to see his son play professional basketball
Possible gaps in careDM2 eye screening, dietitian referral overdue
MedicationsMetformin 500mg, Lisinopril 20mg, Atorvastatin 40mg
PATIENT SUMMARY

Marcus J. Webb, 44-year-old male, DPC Gold member (3 yrs). Primary concerns: T2DM poorly controlled (HbA1c 8.2%) and Hypertension suboptimal (BP 148/94). Medication adherence low (Morisky-8: 3/8). No acute events in last 30 days. Sleep 5 hrs/night (target 7–8). Daily steps 1,200 vs goal 8,000.

PHQ-9 SUMMARY

Latest PHQ-9 score: 11/27 — Moderate Depression. Score has worsened by 2 points vs 3 weeks ago (score 9). Key concerns: low energy, poor concentration, and sleep disturbance endorsed. No suicidal ideation noted. Appetite stable. Recommend: PHQ-9 rescreen in 2 weeks.

SDOH
🏠 HousingStable — lives alone
💼 EmploymentSoftware engineer — high stress
🍎 FoodFood secure, plant-based diet
🚗 TransportHas own vehicle
👮 SupportWife + 2 kids at home
BDOH

Average sleep 5 hrs/night (target 7–8). Screen time high (>6 hrs/day). Alcohol intake low (AUDIT-C 2/12). No tobacco, no illicit substances (DAST-10 1/18). Physical activity very low — 1,200 steps vs 8,000 goal. Stress level self-reported 7/10.

ASSESSMENTS
NAMESCORESTATUSLAST
PHQ-911/27ModerateToday
GAD-78/21Mild-Mod.3 wks
AUDIT-C2/12Low Risk2 mo
STOP-BANG5/8High RiskToday
Morisky-83/8Low Adh.3 wks
DAST-101/18Low Risk2 mo
VITAL GOALS
GOALCURRENT → TARGET
HbA1c8.2% → <7.0%
Blood Pressure148/94 → <130/80
eGFR72 mL/min → >60
Weight100 kg → 88 kg
Daily Steps1,200 → 8,000
BMI32.4 → <28
PATIENT EDUCATION
MODULESTATUSSENT
Diabetes MgmtCompletedApr 10
HTN LifestylePendingJun 1
Dietary ChangesIn ProgressMay 22
CARE GAP TASKS
NAMEPRIORITYASSIGNED
Order HbA1c + lipid panelUrgentDr. Okonkwo
Dietitian referralHighCare Coord.
Follow up PHQ-9HighDr. Okonkwo
Live Listening
Scribe is listening
Transcribing the visit in real time
Dr.So Margaret, tell me how you've been feeling the past few weeks.
Pt.Honestly pretty tired, I'd say fatigued most days for about eight weeks now.
Dr.Let's check your blood pressure — okay, that's reading 148 over 94 today.
Pt.I've been taking the Metformin, but I'll admit I miss a dose maybe three or four times a week.
Dr.Understood. Let's talk about a follow-up plan for the hypertension and adherence.

SuperAI structuring your narration

Generating SOAP note

Transcribing voice narration
Structuring SOAP — S/O/A/P
Extracting diagnoses
Matching care gaps
S — Subjective
CC: DM2 + HTN follow-up. BP consistently elevated at home. Admits to skipping Metformin 3–4x/week.
A — Assessment
1. T2DM — Poorly Controlled
2. Hypertension — Suboptimal
3. Depressive Disorder, Mild
GOALS2 suggested
Update HbA1c target to <7.0%Add
Set daily steps goal to 8,000Add
CARE TEAM TASKS2 suggested
Order HbA1c + lipid panelAdd
Schedule 2-week follow-up callAdd