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Overview

Paw & Care’s AI Documentation feature revolutionizes how veterinary teams create medical records. Instead of typing during patient exams, veterinarians can dictate notes naturally, upload existing documents, or type directly—then let AI automatically generate structured SOAP notes and other clinical documentation formats.

Voice Recording

Record clinical observations during exams with live transcription

Document Upload

Extract text from PDFs, images, audio files, and handwritten notes

Flexible Templates

Generate SOAP notes, dental charts, surgery reports, and custom formats

Clinical Insights

AI-powered suggestions for diagnoses, risks, and treatment options

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Recording Voice Notes

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Starting a Recording

The voice recording interface provides a streamlined workflow for capturing clinical observations:
1

Select Patient and Template

Choose the patient from your records and select your preferred documentation template (SOAP, dental chart, surgery report, etc.)
2

Click Record

Press the Record button to begin capturing audio. The system uses your browser’s microphone with echo cancellation and noise suppression for clear audio.
3

See Live Transcription

As you speak, the browser’s built-in speech recognition provides real-time transcription preview, so you can verify your notes are being captured correctly.
4

Stop and Transcribe

When finished, click Stop. The system uses the live transcription, or falls back to server-side Whisper AI transcription if needed.
  • Pause/Resume: Temporarily pause recording without stopping
  • Timer: Visual display of recording duration
  • Live Preview: Real-time transcription appears during recording
  • Discard: Remove the current recording and start over
  • Play: Review your audio before transcribing

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Audio Quality Tips

Microphone Permissions RequiredYour browser will request microphone access on first use. Make sure to allow access for the recording feature to work.
  • Speak clearly at a normal pace
  • Minimize background noise (clinic machinery, barking)
  • Position microphone 6-12 inches from your mouth
  • Use medical terminology naturally—the AI understands veterinary terms
  • The system automatically enhances audio with echo cancellation and noise suppression

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Document Upload

Upload existing clinical documents to extract and structure information:

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Supported File Types

  • PDF Documents: Lab reports, referral letters, previous records
  • Images: JPEG, PNG, GIF (scanned forms, photos of handwritten notes)
  • Audio Files: MP3, WAV, WebM, M4A (recorded consultations)
  • Text Files: Plain text notes or exported data

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Upload Process

1

Drag and Drop

Drag files directly into the upload area, or click to browse your computer. Maximum file size: 10MB.
2

AI Extraction

The system automatically extracts text from PDFs and images using OCR, or transcribes audio files using Whisper AI.
3

Review Extracted Text

Verify and edit the extracted transcription before generating structured notes.
Handwriting RecognitionThe AI can extract text from handwritten notes, though typed or printed text provides the most accurate results.

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Template-Based Generation

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Available Templates

Paw & Care includes built-in templates for common veterinary documentation:
Standard SOAP (Default)The classic Subjective-Objective-Assessment-Plan format for general practice:
  • Subjective: Chief complaint, history, owner observations
  • Objective: Physical exam findings, vitals, diagnostic results
  • Assessment: Diagnosis or differential diagnoses
  • Plan: Treatment, medications, follow-up instructions
Detail levels: Concise or Detailed

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Selecting Templates

Click the template selector to browse all available options. Each template shows:
  • Template name and type badge
  • Description of use case
  • Sections included (displayed as badges)
  • Detail level (concise or detailed)
The system remembers your most recently used template for faster access.

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AI-Generated Notes

Once you have a transcription, click Generate Notes to create structured documentation:

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How It Works

  1. Context Analysis: AI analyzes the transcription along with patient information (species, breed, known conditions)
  2. Template Mapping: Content is intelligently distributed into the selected template’s sections
  3. Medical Structuring: Clinical observations are formatted with proper medical terminology
  4. Section Generation: Each template section receives relevant extracted information

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Editing Generated Content

All AI-generated content is fully editable:
  • Click into any section to edit text directly
  • Add missing information
  • Remove or refine AI suggestions
  • Copy content between sections if needed
For a Standard SOAP template with a dictation about a vomiting dog:Subjective
Owner reports decreased appetite for 2 days. 
Vomiting once yesterday. Still drinking water normally.
Objective
T: 101.5°F, HR: 90, RR: 20. 
Mild abdominal tenderness on palpation. 
No masses palpable. Mucous membranes pink and moist.
Assessment
Likely mild gastroenteritis. DDx includes dietary 
indiscretion, parasitic infection, foreign body.
Plan
Bland diet (boiled chicken and rice) for 3-5 days. 
Cerenia 1mg/kg PO SID x3 days. 
Recheck if vomiting continues >48hrs.

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Clinical Insights

The AI automatically analyzes generated notes to provide clinical decision support:

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Insight Types

Risk Alerts

High-priority warnings about potential complications or contraindications

Diagnostic Suggestions

Recommended tests or imaging based on presenting signs

Treatment Recommendations

Evidence-based suggestions for protocols and medications

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Priority Levels

  • High Priority (Red): Immediate attention required—potential emergencies or critical findings
  • Medium Priority (Amber): Important considerations for diagnosis or treatment
  • Low Priority (Green): Optional suggestions and best practice recommendations

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Insight Actions

For each insight, you can:
  • Accept: Mark as reviewed and incorporated
  • Reject: Dismiss if not applicable
  • View Details: See full explanation and confidence level
All insights include a confidence score (0-100%) indicating the AI’s certainty level.

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Automated Billing Extraction

Click Generate Billing to automatically extract billable items from your notes:

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Detected Items

The AI identifies:
  • Procedures: Examinations, diagnostics, surgeries
  • Medications: Prescribed drugs with dosages
  • Lab Tests: Blood work, urinalysis, cultures
  • Imaging: X-rays, ultrasounds, CT/MRI
  • Services: Office visits, follow-up consultations

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Billing Review

Each extracted item shows:
  • Item name and type
  • Quantity
  • Unit cost and total
  • Estimated grand total
Copy billing data to clipboard as CSV for import into your practice management system.

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Saving Records

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Save Options

Save work-in-progress notes that need further review or editing. Drafts are visible only to you.

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What Gets Saved

  • All template sections and content
  • Original transcription (for reference)
  • Patient and template information
  • Timestamp and veterinarian name
  • Clinical insights and feedback
Saved records appear in the Medical Records section.

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Sharing and Export

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Export Options

1

PDF/Print

Generate a formatted PDF document with clinic branding. Opens in a new window where you can print or save as PDF.
2

Copy to Clipboard

Copy the entire record as formatted text for pasting into external systems.
3

Email

Send notes via email to referring veterinarians, specialists, or colleagues. Opens your default email client with pre-filled subject and body.

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PDF Format

Exported PDFs include:
  • Patient information header
  • Template name and date
  • All sections with clear formatting
  • Veterinarian signature line
  • Professional styling

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Keyboard Shortcuts

While these aren’t currently implemented in the source code, future versions may include:
  • Ctrl/Cmd + R: Start/stop recording
  • Ctrl/Cmd + G: Generate SOAP notes
  • Ctrl/Cmd + S: Save as draft
  • Ctrl/Cmd + E: Export to PDF

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Best Practices

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Dictation Tips

  1. Use Natural Speech: Speak as you would to a colleague—the AI understands context
  2. Include Patient Details: Mention the patient name, species, and chief complaint
  3. State Vitals Clearly: “Temperature one-oh-one point five” or “T one-oh-one-five”
  4. Spell Unusual Medications: For uncommon drugs, spell them out
  5. Review Before Finalizing: Always review AI-generated content for accuracy

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Template Selection

  • Use Standard SOAP for routine wellness and sick visits
  • Choose Specialist SOAP for referrals and complex cases
  • Select Dental Charts for COHAT procedures
  • Use Surgery Report for all surgical procedures
  • Pick Radiograph Interpretation when imaging is the primary focus

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Quality Assurance

Always Review AI-Generated ContentWhile the AI is highly accurate, it’s essential to review all generated notes for clinical accuracy before finalizing. You are responsible for the medical record’s content.
  • Verify all vitals and measurements
  • Check medication names, dosages, and frequencies
  • Confirm diagnoses match your clinical judgment
  • Ensure all important findings are captured
  • Add any missing information

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Troubleshooting

  • Check browser microphone permissions in settings
  • Ensure no other application is using the microphone
  • Try refreshing the page
  • Verify your browser supports WebRTC (Chrome, Firefox, Safari, Edge)
  • Speak more clearly and slowly
  • Reduce background noise
  • Use the manual “Type” tab for difficult terminology
  • Edit the transcription text before generating notes
If you see “Could not reach the transcription server”:
  • The backend server may not be running
  • Check your internet connection
  • Use the browser’s built-in speech recognition (live transcription)
  • Or use the “Type” tab to enter notes manually
  • Contact your system administrator if the issue persists
  • Complex notes may take 10-20 seconds to process
  • Ensure stable internet connection
  • Try refreshing the page if stuck for >30 seconds
  • Break very long dictations into smaller segments

Medical Records

View, search, and manage all saved medical records

Patient Management

Access patient records to select for documentation

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