Correcting and Finalizing Charts

After Doctora processes your recording, it generates a structured clinical note organized into the same sections your EHR expects. Every field is editable before you send anything. Nothing leaves Doctora until you explicitly approve it.

Understanding the chart layout

The chart editor is organized into tabs that mirror a standard optometric encounter:

• Background -- Patient reason for visit, history of present illness, ocular history, medications, allergies, family history, and review of systems.
• Examination -- All clinical findings: visual acuity, refraction, slit lamp, fundus, tonometry, pupils, and any additional tests included in your template.
• CL Testing -- Contact lens evaluation data. This tab only appears if your exam template includes contact lens fields.
• Assessment and Plan -- ICD-10 diagnoses, CPT codes, care plans, and CPT-to-ICD justification mapping.

Each tab contains collapsible sections. Click a section header to expand or collapse it.

Reviewing the AI output

When a chart first generates, scan through each tab for accuracy. A few things to keep in mind:

• The AI extracts what you said. If you mentioned a finding during the recording, it should appear in the corresponding field. If you did not mention something, the field will typically be left empty rather than fabricated.
• Normal findings are filled in. When you describe a structure as normal or unremarkable, Doctora populates the appropriate "normal" indicator for that field.
• Laterality is preserved. Fields that differ between OD and OS (such as visual acuity, IOP, or slit lamp findings) are separated into right and left columns.

Editing any field

Every field in the chart is directly editable. Depending on the field type, you will see:

• Text fields -- Click into the field and type. Use these for narrative sections like HPI or free-text findings.
• Dropdowns and selects -- Click to choose from predefined options. Common for findings like NPC, cover test results, or examination techniques.
• Toggle switches -- Used for normal/abnormal indicators on grouped findings such as slit lamp or fundus.
• Structured grids -- Visual acuity, refraction, and tonometry use side-by-side OD/OS layouts. Click any cell to edit.

Changes are saved to your encounter automatically as you type. There is no separate "save" button for individual edits.

When to edit vs. when the output is good enough

Not every chart needs manual corrections. Here is a practical guide:

• Edit when clinical accuracy matters. If the AI misheard a value (e.g., IOP of 14 recorded as 40), correct it. Patient safety comes first.
• Edit when your EHR requires specific phrasing. Some EHRs expect particular terminology. If your practice has conventions around how findings are documented, adjust the wording to match.
• Skip editing when the content is substantively correct. Minor phrasing differences that do not change clinical meaning are generally fine. The AI's output does not need to match your exact words--it needs to capture the right clinical information.
• Skip editing normal findings. If everything is within normal limits and the AI has correctly marked it as such, there is nothing to change.

Handling new recordings

If you add a follow-up recording after the initial chart was generated, Doctora displays an alert banner:

• "Outdated - New Recording Available" -- Appears when new recording data has not been incorporated. Click Regenerate Chart to reprocess all recordings and update the chart.
• "Chart May Be Outdated" -- Appears when there is new transcription data that has not been processed yet. Click Update Chart to incorporate the latest data.

Regenerating the chart merges information from all recordings. Any manual edits you made before regenerating will be overwritten, so it is best to regenerate before making fine-tuned corrections.

Reviewing diagnoses and billing

In the Assessment and Plan tab:

• ICD-10 codes are generated based on your clinical discussion. Review each diagnosis for accuracy and remove any that do not apply.
• CPT codes reflect the exam level and any special testing performed. Verify that the codes match the services you actually provided.
• CPT-to-ICD justification links each procedure code to its supporting diagnosis. This mapping is used during EHR sync and can help with claim accuracy.
• Care plans are suggested based on diagnosis history and current findings. Pin the ones you want to keep; unpin any that are not relevant.

Approving and sending to your EHR

Once you are satisfied with the chart:

1. Review each tab one final time. Pay particular attention to Assessment and Plan, since billing codes directly affect reimbursement.
2. Send the chart to your EHR using the sync action available in your encounter view. The exact mechanism depends on your EHR integration (browser extension for cloud EHRs, Windows agent for on-premise systems).
3. After syncing, the data is written into your EHR's encounter record. Fields that have a direct mapping in your EHR are placed in the correct locations. Fields without a mapping are included in an "Additional Notes" overflow section.

You remain in full control. Doctora never sends data to your EHR without your explicit action. Every chart is a draft until you decide it is ready.