Make Your Own PCC Scribe Templates

You can use the default settings provided by PCC, but you’ll get the most out of PCC Scribe if you build templates that work with your visit protocols.

What Is a Scribe Template?

PCC Scribe knows that it’s a pediatric medical scribe, but it doesn’t know how you like to organize your notes. That’s where templates come in.

Templates tell PCC Scribe what information to pull out of the visit transcript and how to organize that information into a note. Templates are customizable and can be linked to your visit protocols.

PCC provides a default template to all Scribe users, but you’ll get the most out of PCC Scribe if you make templates that pair well with your practice’s existing visit protocols.

Navigate to Your Scribe Templates

To find your Scribe templates, open My Account from the File menu, then click on the Scribe Templates tab.

Scribe templates are user-specific. You can create, edit, and delete templates in your account without affecting anybody else.

Get to Know the Default Template

PCC provides a default SOAP Note template to every Scribe user. Double-click to edit it and see how it’s set up.

The template has one component, which every new Scribe user needs to set before using the tool. That component contains instructions for the entire SOAP note.

  • Component: Where the SOAP note will be inserted into the visit protocol when you add it to the patient’s chart.

  • Instructions: What information should be included in the note and how it should be formatted. PCC Scribe uses your instructions to analyze the visit transcript and generate text.

The instructions tell PCC Scribe to create a note with four sections: Subjective, Objective, Assessment, and Plan.

  • Subjective: The Subjective section of the note instructs PCC Scribe to summarize the patient’s perspective on the issue that brought them in for a visit and to format it as a narrative using direct quotes.

  • Objective: The Objective section of the note instructs PCC Scribe to list vitals, physical exam findings, and lab results, or else print “not recorded”. You may not be accustomed to stating vitals measurements, physical exam findings, and lab results out loud, so this section may contain very little information when you use this template.

  • Assessment: The Assessment section of the note instructs PCC Scribe to summarize the clinician’s interpretation of the situation and to format it as a bulleted list using clinical terminology.

  • Plan: The Plan section of the note instructs PCC Scribe to summarize the proposed course of action and to format it as a bulleted list.

You can use the default SOAP note template to start scribing right away, or make your own custom templates.

Create a Custom Template

Create templates that pair with your practice’s visit protocols and the way you like to chart.

Start a New Template

There are three ways to start a new template: Add a new template, clone one of your own, or copy another user’s template.

Click “Add” to start a new template from scratch.

You can also clone one of your existing templates to use as a starting point. Select the template and click “Clone” to create a copy.

Finally, you can copy templates from other users at your practice. Pick a user name from the drop-down at the top of the Scribe Templates tab, select a template, then click “Copy”.

If the copy could overwrite some of your existing configuration, PCC Scribe will let you know.

Once the template has been copied to your account, you can edit all of its parameters without affecting the user you copied it from.

Name the Template

Give your template a unique name. The name should be something that helps you understand what kind of note the template will generate, such as “Derm” for a template that will be used for dermatological visits.

Link to Protocols

Select the protocols for which you are designing this template.

This step is optional but strongly recommended, since PCC Scribe is most useful when it can create notes that are closely tailored to your practice’s visit protocols.

Add Components

Think about which components of the selected visit protocol(s) you want PCC Scribe to be able to fill out, then add them to your template in the order you want them to appear.

At this time, PCC Scribe can only fill out generic text edit components. These are the large text boxes typically used for recording HPI and other narrative parts of the visit.

As your practice integrates the use of PCC Scribe, you may wish to create new components and update your visit protocol configuration. These kinds of changes may optimize your workflows, but they are not essential for getting started with PCC Scribe.

Create Instructions

For each component in your template, create instructions that tell the Scribe what to document and how to format the information.

For example, if you like to document the History of Present Illness as a concise narrative, your instructions to PCC Scribe for the History of Present Illness component could be: “Generate a concise chronological narrative of the patient’s current illness, starting from the first sign or symptom up to the present encounter.”


Alternatively, you could phrase your instructions as a description of what should go in the component: “A concise chronological narrative of the patient’s current illness, starting from the first sign or symptom up to the present encounter.”

You can also tell the Scribe to exclude certain kinds of information, and how it should handle things that aren’t mentioned in the transcript.

For example, your instructions for a scribed Physical Exam could tell PCC Scribe to assume that any system you don’t explicitly mention is normal.

Draft chart note quality is subjective, so no single set of instructions will work for every clinician, but PCC has created some examples to help you get started.

Sample Instructions by Component

Click on each component below to see sample instructions. You can copy and paste these instructions into your templates as a way to get started, or simply use them for inspiration.

Generate a comprehensive Review of Systems (ROS) section in a bulleted format.

Include all symptoms mentioned by the patient or guardian, documenting them as positive findings.

Explicitly summarize Constitutional, Musculoskeletal, and Neurological findings related to the patient’s chief complaint.

For all other body systems not specifically addressed or discussed in the visit transcript (including HENT, Cardiovascular, Respiratory, Gastrointestinal, Genitourinary, Integumentary, Psychiatric, and Endocrine), document them as ‘Negative (Not mentioned during the encounter).’

Generate a comprehensive Physical Exam (PE) note using a clear, structured narrative and bulleted format.

Document the review of interval growth, noting height, weight, head circumference, and BMI (if the patient is 24 months or older), including their percentiles and assessment of changes along the chart’s curve. Reference the use of CDC-recommended growth charts.

Summarize the patient’s general appearance and clearly document the assessment of parent/caregiver-child interactions. Include an explicit statement regarding the assessment for potential signs of abuse.

Document all detailed physical exam findings narrated by the provider, organized by body system (e.g., HENT, Cardiovascular, Skin, Musculoskeletal).

Assume all body systems not specifically dictated by the provider are within normal limits.

Generate the History of Present Illness (HPI) section of the pediatric visit note. The HPI must be a chronological description of the patient’s current illness, starting from the first sign/symptom up to the present encounter.

Extract the primary reason for the visit.

Based on the visit transcript, document the development of the current illness. Include the date/time of the event, mechanism of injury, initial symptoms (e.g., pain location, crying), duration, and any mitigating factors (e.g., medication taken, attempts to use the affected area).

Do not include the Review of Systems (ROS) or Past, Family, and Social History (PFSH) in this HPI section. The output should focus exclusively on the History of Present Illness as defined.

Create a complete dietary history for the patient based on the visit transcript. Format the information as a brief, high-density narrative summary. The note must include an estimate of the quantity, quality, and timing of dietary intake. Specifically capture all typical foods, beverages, medications, and supplements consumed, the portions, the quality of foods, the time and duration of consumption, and the location of consumption (at home or elsewhere).

Generate the Plan of Care section for the visit note. The plan must address every problem discussed during the visit. Format the information as a concise, action-oriented bulleted list. Since this is a pediatric setting, ensure the plan includes, if discussed in the transcript, any recommendations for developmental assessment, and any necessary accommodations related to the patient’s education, school, or community activities.

Generate the Developmental Assessment section of the visit note. Summarize all relevant observations and discussions concerning the patient’s development. Organize the findings by focusing on the four broad areas of early childhood development (physical/physiologic, neurodevelopmental, cognitive, and psychosocial). Additionally, include specific details about any progress or concerns mentioned related to the five developmental streams: gross motor, language, visual-motor problem-solving, social skills, and adaptive skills. The final output should be a concise, structured narrative summary of the assessment.

List the start time, stop time, and total time spent scribing this encounter.

– Start Time: HH:MM:SS EST
– End Time: HH:MM:SS EST
– Total Time: X minutes

Try Using a Generative AI Tool to Create Instructions

If these examples inspire you to create your own instructions but you’re not sure how to get started, you can try asking a third-party generative AI tool for help.

For example, you could ask the tool to: “Create a set of instructions for an ambient pediatric medical scribe to document the patient’s Social History.”

When PCC tried this out, the instructions the generative AI tool came up with were:

“Generate a structured summary of the patient’s Social History based on the visit transcript, organized into a clearly labeled bulleted list. The summary must include the following categories, using explicit statements of “Not Discussed” if information for a category is absent from the transcript:

  • Living Situation: Document who the patient lives with (parents, guardians, siblings, etc.) and the primary caregiver(s).
    School/Childcare: Document the patient’s current grade or daycare setting, academic performance (including any concerns or strengths mentioned), and attendance.

  • Activities/Hobbies: List the patient’s regular activities, sports, or interests.

  • Substance Exposure/Use (as appropriate for age): Document any discussion of exposure to tobacco, alcohol, or illicit substances in the home. For adolescents, document any self-reported substance use. Explicitly state ‘No substance exposure/use discussed’ if not mentioned.

  • Safety/Environment: Document information related to home safety (e.g., smoke detectors, firearm presence/storage), car seat/booster seat use, and helmet use.

  • Pets: Mention any household pets.”

The best way to learn how to write instructions for Scribe templates is to try it out. Create some instructions, see how well they perform when you generate a draft chart note, and refine them to give you better output.

Save and Test the Template

Save the template. Now it’s time to see how it works!

The next time you transcribe a visit that uses one of the protocols linked to the template, notice what works and doesn’t work.

As you review the draft chart note, ask yourself:

  • Is each piece of information in the right component?
  • Are the components in the right order?
  • Is all of the information formatted correctly?
  • Is any information missing?
  • Is the terminology correct?
  • Does the note include any extraneous information?

When you insert the note into the patient’s chart:

  • Does the information show up where you expect it to within the visit protocol?
  • Are there parts of the note that are redundant?
  • Did someone else already chart some of the information also contained in your note?

If the template doesn’t quite meet your standards, make some adjustments and test it again. The best way to learn the art of template creation is through experimentation.

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