Skip to main content

​
Overview

Paw & Care revolutionizes veterinary documentation with AI-powered voice dictation that reduces documentation time by 70% — from 10-15 minutes of manual typing to under 2 minutes per note. This guide covers the complete documentation workflow from recording through finalization.
Clinical Accuracy: All AI-generated notes are marked as “draft” until veterinarian approval. The system assists documentation but never replaces clinical judgment.

​
Documentation Architecture

​
Three Input Methods

Flexible documentation supports diverse workflows:

Voice Recording

Recommended method (70% faster)
  • Record during or after examination
  • Live transcription using browser Speech API
  • Server-side processing with OpenAI Whisper
  • Medical terminology optimization
  • Background recording on iOS
Best for: Real-time documentation, mobile workflows

File Upload

Supports multiple formats
  • Audio: MP3, WAV, WEBM, M4A
  • Documents: PDF, TXT
  • Images: JPG, PNG (OCR)
  • Max size: 10MB
  • AI text extraction
Best for: Pre-recorded notes, referral letters, lab reports

Manual Typing

Direct text entry
  • Type or paste text
  • No AI processing needed
  • Immediate SOAP generation
  • Copy from external sources
  • Fallback if microphone unavailable
Best for: Short notes, updates, system offline

​
Template System

SOAP notes generated using customizable templates: Built-In Templates:
  • Standard SOAP: Default 4-section format (Subjective, Objective, Assessment, Plan)
  • Specialist SOAP: Enhanced sections for complex cases
  • Dental (Canine): Dental-specific fields and grading
  • Dental (Feline): Feline oral health assessment
  • Radiograph Report: Imaging findings documentation
  • Surgery Report: Operative notes and recovery
  • Callback Note: Telephone consultation format
  • Tech Appointment Note: Technician-friendly simplified format
Templates can be customized or new ones created in Templates section (Practice Manager role only). See Custom Templates Guide.

​
Voice Dictation Workflow

​
Step 1: Preparation

1

Select Patient

Navigate to Dictate tab (bottom navigation on mobile, left sidebar on desktop)Patient Selection Dialog:
  • Search by name or breed
  • Filtered list of all patients
  • Shows patient avatar, species, breed, age
  • Recently viewed patients at top
  • Tap patient card to select
Auto-Selection: If coming from active appointment, patient pre-selected automatically
Patient context helps AI generate more accurate notes by understanding species-specific terminology and breed-related conditions.
2

Choose Template

Tap Note Template dropdownTemplate Selection Dialog:
  • Browse all available templates
  • Colored badges show template type
  • Default badge on most-used template
  • Description preview for each
  • Section count (e.g., “4 sections”)
  • Detail level indicator (concise vs. detailed)
Quick Filters:
  • Show only favorites
  • Filter by type (SOAP, Dental, Surgery, etc.)
  • Search by name
Select template that matches visit type.
3

Grant Microphone Permission

First-time setup:When tapping Record for first time:iOS:
  • System prompt: “Paw & Care would like to access the microphone”
  • Tap Allow
  • Permission saved for future use
Web Browser:
  • Browser prompt: “paw-and-care.com wants to use your microphone”
  • Click Allow
  • Permission per-browser, per-device
If Denied:
  • iOS: Settings → Paw & Care → Microphone → Enable
  • Web: Browser settings → Site permissions → Microphone → Allow
  • Or use Type/Upload tabs as alternative

​
Step 2: Recording

1

Start Recording

Tap Start Recording button (large microphone icon)Visual Indicators:
  • Microphone button turns red
  • Recording timer starts (00:00)
  • Waveform animation shows audio levels
  • Red pulsing ring around microphone icon
Live Transcription:
  • Text appears in real-time below microphone
  • Browser Speech Recognition API provides instant feedback
  • Interim text shown in gray (not finalized)
  • Final text appears in black
Recording Quality:
  • Echo cancellation enabled
  • Noise suppression active
  • Auto gain control for consistent volume
  • Codec: AAC or Opus (depending on device)
Best Practices:
  • Hold device 6-12 inches from mouth
  • Speak clearly at normal pace
  • Minimize background noise (close door, silence alerts)
  • Use medical terminology naturally — AI understands veterinary terms
2

Dictate Clinical Findings

Speak naturally while examining patient or immediately after:Example Dictation (Standard SOAP):“Bella, 8-year-old spayed female Golden Retriever, presented today for annual wellness examination. Owner reports Bella is doing well overall, eating and drinking normally, no vomiting or diarrhea. Activity level good, no coughing or sneezing. Up to date on heartworm and flea prevention.”“On physical exam, Bella is bright, alert, and responsive. Body condition score 5 out of 9, weight today 65 pounds, which is stable from last visit. Temperature 101.2 degrees, heart rate 90, respiratory rate 24. Mucous membranes pink and moist, capillary refill time less than 2 seconds. Dental exam shows moderate tartar buildup on upper premolars, grade 2 out of 4. No gingivitis noted. Cardiac auscultation reveals regular rhythm, no murmurs. Lung sounds clear bilaterally. Abdominal palpation soft, non-painful, no masses detected. Skin and haircoat in good condition, no parasites observed. Musculoskeletal exam unremarkable, good range of motion all limbs.”“Assessment: Bella is healthy overall. Dental disease grade 2. Due for rabies and DHPP vaccinations today.”“Plan: Administered rabies and DHPP vaccines. Discussed dental health with owner, recommended dental cleaning within next 6 months. Prescribed dental chews for home care. Recommended maintaining current diet and exercise. Recheck in 1 year for next annual wellness exam.”Dictation Tips:
  • Use standard SOAP structure naturally (AI will re-organize)
  • Include specific numbers (weights, temperatures, lab values)
  • Speak full medication names and dosages
  • Mention chronic conditions and allergies
  • State what’s normal AND abnormal
3

Pause or Resume

During Recording:Pause button available if need to:
  • Answer phone or talk to owner
  • Step out of exam room
  • Check reference materials
  • Consult with technician
Tap Pause (yellow icon):
  • Recording stops but not finalized
  • Timer pauses
  • Live transcription frozen
  • Audio saved to that point
Tap Resume (play icon):
  • Recording continues from pause point
  • Timer resumes
  • Live transcription continues
  • Audio appended seamlessly
Pausing does NOT stop browser Speech Recognition, only the audio recording. Transcription may continue capturing ambient speech.
4

Stop Recording

When dictation complete, tap Stop button (red square)Automatic Actions:
  1. Recording finalized
  2. Audio file created (WebM format)
  3. Microphone stream closed
  4. Timer stops and shows total duration
  5. Play button appears for audio playback
  6. Live transcription preserved
  7. Transcribe button enabled
Audio File:
  • Stored in browser memory (not uploaded yet)
  • Can preview by tapping Play button
  • File size shown (typically 1-3 MB per minute)
  • Delete and re-record if needed

​
Step 3: Transcription

1

Review Live Transcription

Before processing with AI, check browser-generated transcription:Live Transcription Preview:
  • Appears below microphone during recording
  • Shows what Speech API captured
  • Usually 80-90% accurate
  • May have spelling errors or mishear medical terms
If Live Transcription Good:
  • This text will be used for SOAP generation
  • No need to wait for Whisper API processing
  • Click directly to Generate Notes (skips transcription step)
If Live Transcription Poor or Empty:
  • Proceed to AI transcription with Whisper
  • More accurate medical terminology
  • Slower (8-15 seconds processing)
2

AI Transcription (OpenAI Whisper)

Tap Transcribe buttonProcessing Steps:
  1. Upload Audio: File sent to backend server as base64-encoded string
    • Progress: 0-20%
    • Time: 2-4 seconds depending on file size and connection
  2. Server Processing: Backend sends to OpenAI Whisper API
    • Progress: 20-80%
    • Time: 5-10 seconds per minute of audio
    • Whisper model: whisper-1 (multilingual large model)
    • Language: English (configurable)
  3. Text Extraction: Whisper returns transcription
    • Progress: 80-95%
    • JSON response with text and confidence metadata
  4. Post-Processing: Medical term correction
    • Progress: 95-100%
    • Spell-check against veterinary dictionary
    • Capitalize drug names, anatomical terms
    • Format numbers and measurements
  5. Display: Transcription appears in text area
    • Editable text field
    • Word count shown
    • Estimated SOAP length indicator
Transcription Box:
  • Full text displayed
  • Edit directly if any errors
  • Add additional context AI may have missed
  • Copy/paste supported
  • Undo/redo available
Accuracy Optimization: Whisper achieves 95%+ accuracy on medical terminology when audio is clear. Mumbling, background noise, or accents may reduce accuracy.
3

Edit Transcription (Optional)

Review and correct transcription before SOAP generation:Common Corrections:
  • Drug names: “carro profen” → “carprofen”
  • Measurements: “sixty five pounds” → “65 pounds”
  • Medical terms: “borborygmi” misheard as “more vore big my”
  • Breed names: “retriever” → “Golden Retriever”
  • Owner names: Correct spelling for records
Editing Tools:
  • Click anywhere in text to edit
  • Standard keyboard shortcuts work (Ctrl+C, Ctrl+V, Ctrl+Z)
  • Character count updates in real-time
  • Save draft if need to finish later
Better transcription quality = better SOAP note quality. Spend 30 seconds reviewing transcription to save 2 minutes editing SOAP notes.

​
Step 4: SOAP Note Generation

1

Generate AI SOAP Notes

Tap Generate Notes button (wand icon)AI Processing (OpenAI GPT-4):Request Payload sent to backend:
{
  "transcription": "[full transcription text]",
  "templateName": "Standard SOAP",
  "templateSections": [
    {"id": "subjective", "name": "Subjective"},
    {"id": "objective", "name": "Objective"},
    {"id": "assessment", "name": "Assessment"},
    {"id": "plan", "name": "Plan"}
  ],
  "patientName": "Bella",
  "species": "dog",
  "breed": "Golden Retriever",
  "detailLevel": "concise"
}
GPT-4 Prompt (simplified):
You are a veterinary medical scribe. Convert the following 
dictation into a structured SOAP note for a dog patient named 
Bella (Golden Retriever).

Output format: JSON with keys: subjective, objective, assessment, plan

Detail level: Concise (focus on essential information)

Transcription:
[dictation text]

Generate professional, clinically accurate SOAP sections.
Processing Time: 15-30 seconds depending on note lengthResponse: Structured JSON with SOAP sections
2

Review Generated SOAP Sections

AI-generated content appears in structured format:Subjective Section (blue background):
  • Chief complaint
  • Owner-reported symptoms
  • History since last visit
  • Medications and diet
  • Behavior changes
Objective Section (green background):
  • Vital signs (TPR, weight, BCS)
  • Physical examination findings
  • Diagnostic results
  • Observed behaviors
  • Measurable data
Assessment Section (purple background):
  • Primary diagnosis
  • Differential diagnoses
  • Problem list
  • Severity grading
  • Prognosis
Plan Section (pink background):
  • Treatments administered
  • Prescriptions and dosages
  • Diagnostic tests ordered
  • Recheck interval
  • Owner education provided
  • Follow-up appointments
Each Section:
  • Colored header with section name
  • Editable text area
  • Word count
  • Expand/collapse button
  • Copy section button
  • AI confidence indicator (if available)
3

Edit SOAP Sections

Click into any section to modify:Editing Interface:
  • Full-height text area when focused
  • Markdown formatting supported (bold, italic, lists)
  • Spell-check enabled
  • Character limit: 5000 per section
  • Auto-save draft every 30 seconds
Common Edits:
  • Add missed details from examination
  • Correct AI misinterpretations
  • Adjust phrasing for clinic style
  • Add context AI didn’t infer
  • Remove irrelevant information
Undo/Redo:
  • Ctrl+Z to undo changes
  • Ctrl+Y to redo
  • Revision history saved (view previous versions)
Quality vs. Speed: AI achieves 85% clinical appropriateness. Most notes require only minor edits (1-2 minutes) rather than complete rewrites (10-15 minutes).

​
Step 5: Clinical Insights

1

Review AI-Generated Insights

After SOAP generation, Clinical Insights panel appears (right sidebar or below SOAP on mobile)Insight Types:🚨 Risk Insights (red):
  • Potential complications
  • Contraindications for treatments
  • Drug interactions
  • Breed-specific risks
  • Age-related concerns
Example:
Risk: Dental disease progression

Confidence: 78%

Description: Grade 2 dental disease at age 8 increases risk 
of periodontal disease. Untreated, may progress to tooth loss 
and systemic infection within 12-24 months.

Recommendation: Schedule dental cleaning within 6 months.
💡 Diagnosis Insights (blue):
  • Differential diagnoses
  • Condition likelihood
  • Supporting evidence from exam
  • Diagnostic tests to confirm
Example:
Diagnosis: Possible early osteoarthritis

Confidence: 65%

Description: Mild decreased range of motion in right hip 
combined with age and breed predisposition suggests early 
osteoarthritis.

Recommendation: Consider hip radiographs, trial NSAIDs, 
discuss joint supplements.
✨ Suggestion Insights (green):
  • Treatment options
  • Preventive care recommendations
  • Client education topics
  • Follow-up scheduling
Example:
Suggestion: Weight management

Confidence: 82%

Description: BCS 5/9 indicates slight overweight. Golden 
Retrievers prone to obesity and joint issues.

Recommendation: Reduce daily calories by 10%, increase 
exercise duration, recheck weight in 6 weeks.
2

Provide Feedback on Insights

For each insight:Accept (👍 green button):
  • Insight marked as “accepted”
  • Incorporated into treatment plan if applicable
  • Positive feedback trains AI
  • Insight badge turns green with checkmark
Reject (👎 red button):
  • Insight marked as “rejected”
  • Removed from display
  • Negative feedback trains AI
  • Insight badge turns red with X
Ignore (no action):
  • Insight remains with “pending” status
  • Visible for reference but not incorporated
  • No feedback signal sent
Continuous Learning: Your accept/reject feedback improves AI accuracy over time. The system learns your clinical preferences and clinic protocols.
3

Incorporate Insights into Plan

Accepted insights can be added to SOAP Plan section:Manual Method:
  • Copy insight text
  • Paste into Plan section
  • Edit as needed for clinical note style
Auto-Incorporate (coming soon):
  • Tap “Add to Plan” button on insight
  • Text automatically appended to Plan section
  • Formatted appropriately
  • Maintain manual edit control

​
Saving and Finalizing Records

​
Save Options

1

Choose Record Status

Three save states available:
Status: DraftUse When:
  • Documentation incomplete
  • Awaiting lab results or diagnostics
  • Need to consult reference materials
  • Finishing notes later
  • Technician started record for vet review
Characteristics:
  • Can edit unlimited times
  • Not visible to front desk/billing
  • Yellow draft badge
  • Listed in “My Drafts” filter
  • No audit log entry (still in progress)
Workflow: Tap Save as Draft button → Confirmation message → Continue working or close
2

Save to Database

Tap appropriate save button:Backend Processing:
  1. Data Validation:
    • Required fields present (patient, template, date)
    • SOAP sections within length limits
    • Status transition valid (Draft → Pending → Finalized)
    • User has permission for selected status
  2. Database Insert (Supabase): Record saved to medical_records table: 
    INSERT INTO medical_records (
  id,
  pet_id,
  pet_name,
  owner_name,
  vet_name,
  template_name,
  record_date,
  status,
  soap_subjective,
  soap_objective,
  soap_assessment,
  soap_plan,
  notes,
  audio_url,
  created_at
) VALUES (...)
  3. Audit Log Entry (if not draft): 
    INSERT INTO audit_log (
  user_name,
  action,
  resource,
  resource_id,
  details,
  timestamp
) VALUES (
  'Dr. Sarah Chen',
  'Medical record created',
  'medical_records',
  'rec-123',
  'Standard SOAP for Bella',
  NOW()
)
  4. Notification (if Pending Review):
    • Push notification to assigned reviewer
    • Email notification as backup
    • Badge count increments in “Needs Review” queue
  5. Link to Appointment (if applicable):
    • Appointment record updated with medical_record_id
    • Appointment status can progress to “Completed”
    • Medical record accessible from appointment card
Success Confirmation:
  • Green checkmark notification: “Record saved as [status]”
  • Record ID displayed (e.g., “rec-20260305-123”)
  • Auto-redirect to Medical Records list or appointment
3

Handle Save Errors

If save fails:Common Errors:Network Error:
  • Symptom: “Could not connect to server”
  • Cause: No internet connection or server down
  • Solution:
    • iOS: Record saved to local SQLite database
    • Will auto-sync when connection restored
    • Green “Saved locally” message displayed
    • Sync indicator shows pending upload
Validation Error:
  • Symptom: “Required field missing” or “Invalid data”
  • Cause: Missing patient selection, empty sections
  • Solution:
    • Error message highlights specific field
    • Fix issue and retry save
    • Draft automatically preserved (no data loss)
Permission Error:
  • Symptom: “You don’t have permission to finalize records”
  • Cause: User role (Technician) cannot finalize
  • Solution:
    • Save as “Pending Review” instead
    • Request Practice Manager enable finalization permission
Timeout Error:
  • Symptom: “Save timed out after 30 seconds”
  • Cause: Slow network or large audio file
  • Solution:
    • Retry save (data preserved)
    • Remove audio attachment if very large
    • Check network speed

​
Offline Documentation (iOS Only)

​
Offline Workflow

Mobile app supports full documentation without internet:
1

Detect Offline Mode

When network connection lost:Visual Indicators:
  • Orange banner at top: “Offline — Changes will sync when online”
  • Cloud icon with slash in status bar
  • Sync pending badge on app icon
Functional Changes:
  • AI transcription unavailable (use Type tab)
  • SOAP generation unavailable (manual entry)
  • Clinical insights unavailable
  • Billing generation unavailable
  • Patient data cached (last synced state)
2

Create Records Offline

Available Features:
  • Select patient (from cached list)
  • Choose template
  • Manual text entry for each SOAP section
  • Save as Draft
  • Link to appointment
Not Available Offline:
  • Voice recording with AI transcription
  • AI SOAP generation
  • File upload with extraction
  • Clinical insights
  • Finalization (requires online verification)
Workaround: Use device’s native Voice Memos app to record audio, then upload/transcribe when back online.
3

Offline Storage

Records saved to local SQLite database:Storage Location: iOS app sandbox (secure)Data Stored:
  • All SOAP content
  • Patient ID and name
  • Template selection
  • Draft status
  • Creation timestamp
  • User ID
Storage Limit: Up to 100 MB (approximately 1000 records)Persistence: Survives app restarts, remains until synced
4

Automatic Sync When Online

When connection restored:Sync Process:
  1. Detection: App detects network availability
  2. Banner Update: “Back online — Syncing…”
  3. Queue Processing:
    • Offline records uploaded in order created
    • One at a time to prevent conflicts
    • Progress indicator shows X of Y synced
  4. Conflict Resolution:
    • If record edited on another device: Last-write-wins
    • User notified: “Record updated on server, local changes discarded”
    • Option to view conflicts and merge manually
  5. Completion: “All changes synced” green banner
  6. Local Data: Cleared from device after successful sync
Sync Time: Approximately 2-5 seconds per record
Data Safety: Records encrypted in local database using iOS Keychain. If app deleted before sync, data lost. Recommend syncing regularly.

​
Documentation Best Practices

​
Speed Optimization

Before Exam

Preparation (30 seconds):
  • Review previous SOAP notes
  • Note chronic conditions
  • Check vaccination status
  • Review known allergies
  • Have template pre-selected
Impact: Faster dictation, fewer missed details

During Exam

Real-Time Recording (2-3 minutes):
  • Dictate while examining
  • Speak findings as observed
  • Include normal and abnormal
  • State measurements aloud
  • Owner present hears professionalism
Impact: No post-exam documentation time, higher accuracy

After Exam

Quick Review (1-2 minutes):
  • Generate SOAP notes immediately
  • Rapid section review
  • Accept/reject insights
  • Finalize before next patient
Impact: Context fresh, details accurate, no backlog

End of Day

Final Cleanup (5-10 minutes):
  • Finalize any remaining drafts
  • Review pending records
  • Quality check day’s notes
  • Ensure all linked to appointments
Impact: No carried-over work, clean records, billing ready

​
Quality Assurance

1

Self-Review Checklist

Before finalizing, verify:Completeness:
  • All SOAP sections have content
  • Vital signs recorded (TPR, weight)
  • Diagnosis stated clearly
  • Treatment plan specific (not vague)
  • Follow-up interval mentioned
  • Owner education documented
Accuracy:
  • Patient name correct
  • Medications spelled correctly with doses
  • Measurements include units (lbs, kg, degrees)
  • Dates correct (current visit, next recheck)
  • No contradictions between sections
Professional:
  • No abbreviations unless standard
  • Complete sentences (avoid shorthand)
  • Objective language (avoid “seems” or “appears”)
  • Appropriate medical terminology
  • Legible to other veterinarians
2

Peer Review (Recommended)

Monthly Record Audits:Practice Managers randomly select 5-10 records per veterinarian:Evaluation Criteria:
  • Documentation completeness
  • Clinical accuracy
  • Compliance with standards
  • Consistency across similar cases
  • Appropriate use of AI tools
Feedback Session:
  • Discuss strengths and improvement areas
  • Share best practices across team
  • Identify template modifications needed
  • Calibrate AI acceptance thresholds

​
Troubleshooting

Symptoms: No recording, no waveform, permission deniedSolutions:iOS:
  1. Settings → Paw & Care → Microphone → Enable
  2. Restart app
  3. Check device microphone with Voice Memos app
  4. If hardware issue, use Type tab
Web:
  1. Browser settings → Site permissions → Microphone → Allow
  2. Refresh page
  3. Try different browser
  4. Check operating system microphone permissions
Error: “Could not generate SOAP notes” or “AI service unavailable”Causes:
  • Backend server offline
  • OpenAI API rate limit exceeded
  • Network timeout
  • Invalid transcription format
Solutions:
  1. Wait and Retry: Transcription preserved, click Generate Notes again after 1 minute
  2. Manual Entry: Use Type tab to create SOAP manually from transcription
  3. Contact Support: If persistent, report backend issue
  4. Rate Limit: Practice-wide limit is 100 requests/minute; wait briefly
Missing insights after SOAP generationReasons:
  • Insufficient data in SOAP notes (too brief)
  • Common/routine case (no notable insights)
  • Backend insight service unavailable
Solutions:
  • Add more detail to SOAP sections and regenerate
  • Check if insights collapsed (expand panel)
  • Not all cases have insights (e.g., simple nail trim)
  • Non-critical feature, can finalize without insights
Error: “You don’t have permission” or “Record must be reviewed first”Causes:
  • User role (Technician) lacks finalization permission
  • Record in Pending Review status awaiting approval
  • Required fields missing
Solutions:
  • Technicians: Save as “Pending Review” instead, veterinarian will finalize
  • Veterinarians: Check role permissions in Settings → User Management
  • Missing Fields: Complete all required sections highlighted in red

​
Next Steps

Custom Templates

Create specialized SOAP templates for your practice’s unique workflows

Billing Integration

Learn how to generate billable items from SOAP notes automatically

Daily Workflow

See documentation workflow in context of complete daily operations

Bulk Operations

Manage multiple records efficiently with batch operations

Build docs developers (and LLMs) love

Get started for freeTalk to us