Notermed

Specialties

AI scribe for pulmonology and sleep clinics

A pulmonary visit carries numbers a generic note has no line for. Among them: FEV1 as percent predicted and the FEV1/FVC ratio, the GOLD grade, home oxygen flow rate and hours per day, CPAP pressure settings with compliance and leak data, which inhaler and whether the technique was checked. Notermed ships four pulmonary formats with a section for each, and the draft fills only the ones the visit actually spoke to.

  • Built-in formats4
  • Sections across them34
  • Structure reviewed

What a pulmonary note captures

Every line below is a field in one of the four built-in pulmonary formats. The draft fills a line only when the visit spoke to it; a section with nothing stated is left out rather than padded.

  1. 01

    Interval History

    • Daytime symptom frequency per week
    • Nighttime awakenings
    • Exercise limitation
    • Need for rescue therapy
    • Rescue inhaler (SABA) use per week, and triggers identified
    • Exacerbations: hospitalizations, ED visits, oral corticosteroid courses
    • Dyspnea level, with mMRC grade or CAT score when mentioned
    • Exertional tolerance and functional limitations
    • Cough and sputum: volume, color, change from baseline
    • Exacerbations: frequency, severity, hospitalizations
    • Antibiotic or corticosteroid courses
    • Smoking status, when mentioned
    • CPAP, BiPAP, or ASV adherence: average hours per night
    • Percentage of nights used, from device data
    • AHI or residual AHI on therapy, from the device download
    • Daytime sleepiness, with ESS score when stated
    • Snoring, witnessed apneas, nocturnal awakenings, non-restorative sleep
  2. 02

    Asthma Triggers

    • Triggers identified or suspected
    • Allergens, exercise, cold air, GERD
    • Occupational exposures and viral infections
  3. 03

    Inhaler Technique & Adherence

    • Adherence to controller therapy
    • Technique issues noted
  4. 04

    Medications

    • Controller and rescue medications
    • Device type, dose, and frequency
    • Any change made today
    • Current bronchodilator regimen
    • Rescue use frequency
    • Sedatives or other medications affecting respiratory drive
    • Medications stated aloud or in an attached list
  5. 05

    Physical Examination

    • Vital signs including oxygen saturation
    • Lung auscultation findings
    • Vital signs including oxygen saturation at rest
    • Chest findings
    • BMI or weight change, when documented
  6. 06

    Assessment

    • Control classification: well-controlled, partly controlled, or uncontrolled
    • GOLD grade and stability, as stated
    • Severity of the sleep apnea
    • How effective the current therapy is
    • A problem list of the diagnoses the clinician stated
    • ICD-10 codes flagged for billing verification
    • Severity, only where the clinician stated it
  7. 07

    Plan

    • Medication adjustments
    • Trigger management
    • Action plan review
    • Referrals
    • Follow-up interval
    • Pulmonary rehabilitation
    • Smoking cessation
    • Oxygen changes
    • Follow-up
    • Pressure adjustments and mode change
    • Mask change
    • Weight management
    • Repeat study
    • Grouped by problem, numbered
    • Sleep: device start and settings, pressure change, switch to BiPAP
    • Sleep: titration or BiPAP ASV study, mask and settings, driving advice
    • Sleep: weight loss and GLP-1 discussion
    • Pulmonary: repeat CT follow-up, at the Fleischner interval when stated
    • Pulmonary: ABG, complete PFTs with lung volumes and diffusion
    • Pulmonary: tobacco cessation, bronchodilator benefit discussion
  8. 08

    Spirometry / Pulmonary Function

    • FEV1 as percent predicted, FVC, FEV1/FVC ratio
    • GOLD grade as assigned
  9. 09

    Oxygen Therapy

    • Home oxygen flow rate
    • Hours per day
    • Delivery device
  10. 10

    Device Data

    • Device type and current pressure settings
    • Mask type
    • Compliance and leak data
  11. 11

    Chief Complaint (CC)

    • A short reason for the visit
    • For example sleep study, pulmonary nodules, CPAP compliance review
  12. 12

    History of Present Illness (HPI)

    • Referral source
    • Snoring, witnessed apnea, daytime fatigue
    • Dyspnea, cough, sputum, hemoptysis
    • Sleep schedule and sleep quality
    • Study or test results the clinician reviewed aloud
    • On follow-up: interval symptoms, device and mask use
    • On follow-up: current compliance metrics and AHI
  13. 13

    Past Medical History (PMHx)

    • Relevant medical history, where provided
  14. 14

    Past Surgical History (PSHx)

    • Prior surgery, where provided
  15. 15

    Family History (FHx)

    • Relevant family history, where provided
  16. 16

    Social History

    • Smoking status: current, former, or never
    • Vaping, alcohol, drug use
    • Pack-years, only when given or directly calculable
  17. 17

    Review of Systems (ROS)

    • General, HEENT, Cardiovascular, Pulmonary
    • Gastrointestinal, Genitourinary, Musculoskeletal
    • Neurological, Psychiatric
    • Only the systems raised, with the findings actually stated
  18. 18

    Allergies

    • Allergies as stated
    • No known allergies only when someone said so
  19. 19

    Vitals

    • BP, HR, RR, temperature
    • Height, weight, BMI
    • SpO2 on room air or supplemental oxygen, with liter flow
  20. 20

    Physical Exam

    • By system: GEN, NECK, RESP, CV
    • GI, DERM, EXT, NEURO
    • Only findings actually stated or dictated
  21. 21

    Results / Diagnostics

    • Labs
    • PFTs: FEV1, FVC, FEV1/FVC, TLC, RV, DLCO, 6-minute walk
    • Imaging: chest X-ray or CT, with the report impression preserved
    • Sleep study: recording and sleep time, apneas and hypopneas
    • AHI on 3% (AASM) and 4% (CMS) criteria, oximetry nadir, severity

The formats

Four built-in formats

  1. Asthma Follow-up

    Asthma return visit per GINA stepwise management.

    7 sections

  2. COPD Follow-up

    COPD return visit per GOLD 2024 guidelines.

    7 sections

  3. CPAP / Sleep Apnea Follow-up

    Sleep apnea / CPAP therapy review per AASM guidelines.

    6 sections

  4. Pulmonology Note

    Pulmonary, Critical Care & Sleep Medicine encounter note.

    14 sections

Built in a pulmonary practice

Notermed is developed in continuous consultation with a practicing US physician with more than three decades of clinical experience. It grows in ongoing consultation with that physician and his practice, one real workflow at a time.

How Notermed is built

Questions from pulmonology and sleep clinics

Does it capture spirometry values, or just say "spirometry reviewed"?
The COPD follow-up format has a Spirometry / Pulmonary Function section that records FEV1 as percent predicted, FVC, the FEV1/FVC ratio and the GOLD grade as assigned. If those numbers were said in the visit, they land in the draft; if they were not, the section is left out rather than padded.
What does the CPAP follow-up record from the device?
Its Device Data section captures the device type and current pressure settings, the mask type, and compliance and leak data as stated during the visit. The Interval History and Plan sections carry the rest of the conversation.
Is home oxygen documented in a structured way?
Yes. The COPD follow-up has an Oxygen Therapy section for home oxygen flow rate, hours per day and the delivery device, so the numbers a payer or a colleague looks for are on their own lines rather than buried in a paragraph.
Was this actually built with a pulmonologist?
Notermed is developed in continuous consultation with a practicing US physician with more than three decades of clinical experience. It grows in ongoing consultation with that physician and his practice, one real workflow at a time. The four pulmonary formats sit first on the note formats page.
Can I change the format or add my own?
You can add formats of your own, and save your own copy of any built-in one. The built-in ones are a starting point that already knows the vocabulary, not a fixed template.

What holds true for your patient data

These apply from your first free session, on every plan, whichever format you write in. The technical detail is on the security and HIPAA page.

  • A BAA first

    We sign a Business Associate Agreement with your clinic before any patient data is processed.

  • US servers only

    Patient data is stored and processed only on servers in the United States.

  • Encrypted throughout

    Recordings, transcripts and notes are encrypted in transit and at rest.

  • Never training data

    Patient conversations are never used to train AI models.

  • Yours to sign

    Every note is a draft until the clinician reviews it and signs it.

This page describes how a note is structured. It is not clinical guidance, and the clinician who signs the note remains responsible for the record.

See it on one of your own pulmonary visits

Bring a consultation. We will record it, show you the draft in your format, and tell you plainly if Notermed is not a fit yet.

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