AI scribe and clinic software for infectious disease and travel clinics

The infectious disease note, by clinic

A pre-travel note starts with the itinerary, the countries, dates, rural or urban stays and activities, then vaccination history, medicines, pregnancy and immune status, the vaccines given or planned with dose numbers, malaria risk and the prophylaxis chosen. Yellow fever has its own rules. In the US, the CDC states that a certificate of yellow fever vaccination is valid from 10 days after the dose and for the person's lifetime, and that a traveller with a contraindication needs a signed, dated exemption letter on letterhead that states it.¹ The note records the contraindication in the words the physician used, and the stamped certificate and exemption letter stay with the vaccination centre's own process.

An OPAT note carries the indication, the organism and its sensitivities, the antimicrobial with dose, route and frequency, the line, the start and planned end dates, and the monitoring. The UK good practice recommendations ask for blood test monitoring at least weekly for every OPAT patient, whatever the length of treatment, and for a responsible physician to be clearly identified for each one.² A template with those fields keeps the end date and the weekly bloods in every note.

Notification is a legal duty that differs by country. In England, registered medical practitioners must report a suspected notifiable disease to the UK Health Security Agency, by phone to the local health protection team within 24 hours for an urgent disease and through the online service within 3 days for every case, without waiting for laboratory confirmation.³ Scotland, Wales and Northern Ireland publish their own guidance. In the US, each state or territory sets which diseases must be reported, providers tell their public health department, and states inform the CDC voluntarily.⁴ Gulf and European clinics follow their own regulator's list and route. wai does not file notifications. The physician makes the report, and the note records that it was made, when and to whom.

Codes are suggested from the note with the line each rests on, for the physician to confirm. In ICD-10, the edition used in the UK and the Gulf, typical codes are B50.9 Plasmodium falciparum malaria, unspecified, A15.0 Tuberculosis of lung, confirmed by sputum microscopy with or without culture, B24 Unspecified human immunodeficiency virus [HIV] disease, Z24.3 Need for immunization against yellow fever and L03.1 Cellulitis of other parts of limb. US practices see ICD-10-CM forms, which differ here, B20 Human immunodeficiency virus [HIV] disease and Z23 Encounter for immunization among them. SNOMED CT concepts are suggested alongside. Procedure and administration codes, CPT in the US and OPCS in the UK, stay with the clinic's coder.

The letters an infectious disease clinic sends, and to whom

The Academy of Medical Royal Colleges recommends writing most outpatient letters to the patient with a copy to the GP, and says this should be the default setting for an AI scribe.⁵ In infectious disease, who receives the copy is a decision in its own right. For HIV and sexual health, the physician copies the GP only where the patient has agreed, and the consent is recorded in the note.

The OPAT plan goes to the GP and the community nursing team as a referral letter, with the antimicrobial, dose, line care, the weekly bloods, the planned end date and who to call. The end-of-treatment letter records the outcome and any oral step-down. Results letters explain serology, cultures and viral loads with the physician's comment. Pre-travel advice goes to the patient as a summary of the vaccines given, the doses still due and the malaria tablets with how to take them, and fit-to-fly letters cover a traveller recovering from an infection.

Referral letters onward, to a hepatologist for viral hepatitis or to a surgeon for source control, carry the question for the specialist and are drafted from the whole record. The structure is in the referral letter, and the consent question for sensitive consultations in patient consent for AI scribes.

Infectious disease in the patient's own language

Travel and migrant health bring a wide mix of languages into one clinic. wai captures consultations in 60 languages, among them English, Arabic, Spanish, French, Portuguese, Italian, Russian, Polish, Turkish, Urdu and Mandarin. English can be mixed in one consultation with Spanish, French, Portuguese, Russian, Italian, Dutch, German, Hindi or Japanese, and the other languages are captured in the language spoken.

An exposure history is only as good as the patient's account of it, where they stayed, what they ate, who was unwell around them. The signed note is written in English for the record, or in another language the clinic chooses, and the patient's summary, with the antimalarial instructions or the OPAT line care advice, can be translated beside it. Crisis and emergency numbers stay exactly as written. More in multilingual consultations and on the multilingual AI scribe page.

Clinic software for infectious disease clinics, doses and bloods on time

A travel clinic lives on courses of doses. In wai Admin, patients request the first appointment through booking links that read each clinician's calendar, cancellations backfill from the waitlist, and reminders go out. Proactive care sends the recall for the second and third doses of a vaccine course and for a booster, each message approved by a person. Deposits, invoices, payment links and insurer invoices run through the clinic's own Stripe account.

OPAT and HIV care live on bloods. Proactive care sends the weekly OPAT blood recall and the routine viral load reminder, and the after-visit companion tracks each prescription, referral and follow-up until it is done. In the UK, pathology orders go out and results come back through TDL, and private prescriptions, malaria prophylaxis included, are issued and signed through SignatureRx. Routine results reach the patient with the physician's own comment and a plain explanation of each marker, while a new diagnosis is given by the physician in person.

Calls, email, web forms and WhatsApp messages land in one thread per patient, with replies drafted in the clinic's voice and approved by a person before they are sent. Before each review the physician sees a sourced brief of the patient, each fact traced to the letter, result or visit it came from. A family member or carer can have access with the patient's consent. The full front desk is on the clinic management software page.

One OPAT consultation, start to finish

Take a 67-year-old with cellulitis of the right lower leg that has spread despite five days of oral antibiotics, seen in the infection clinic to start OPAT. The physician confirms a non-severe penicillin rash in childhood, marks the edge of the erythema, reviews the bloods and agrees once-daily intravenous ceftriaxone through a midline, a planned seven days, bloods weekly and a review on day five with a view to oral step-down.

The draft note holds the history, the allergy and its nature, the examination, the antimicrobial with dose, route and frequency, the line, the start and planned end dates, the bloods and the review date, and names the physician responsible. The suggested code is L03.1 Cellulitis of other parts of limb, tied to the line where the diagnosis was made. The physician corrects the line type, which the draft had heard as a PICC line, confirms the code and signs.

Three documents go out. The letter to the patient explains the treatment, how the community nurse will visit, the signs that mean calling the clinic, and the day five review, with a copy to the GP. The OPAT plan goes to the community nursing team with the dose, the line care and the bloods. The front desk sends the booking link for the day five review and the blood recall, and the after-visit companion tracks the review until it happens.

The evidence behind wai's method

The note is one part of the day the evidence measures. In a randomised trial of 238 outpatient physicians across 14 specialties at UCLA Health, the ambient scribe with a significant effect cut the time spent writing each note by about 41 seconds, against 18 seconds in usual care.⁶ At The Permanente Medical Group, 3,442 physicians used an ambient scribe across 303,266 encounters in its first ten weeks.⁷ wai is built on that finding, so it takes on the letters, the dose recalls and the blood monitoring as well as the note.

Infection practice is written down for a reason. The UK OPAT recommendations rest on weekly bloods and a named responsible physician for every patient,² and notification law in England rests on a report made on suspicion.³ A note that records each of these in a fixed field leaves an audit trail without extra work.

A draft stays a draft until a person signs it. The Academy of Medical Royal Colleges says the clinician checks every document a scribe produces,⁵ and wai holds every draft until the physician signs it. In a systematic review of 33 studies, 76% found at least one outcome better when patient and physician shared a language other than English.⁸

Measured in a working clinic. At The Wellness in London, which runs on wai every day, every clinician has 15 hours a week back, as published in the customer story.⁹

Where to start

Start with the clinic that writes the most letters, usually OPAT or travel. Build the template with the fixed fields, antimicrobial, dose, route, end date and bloods for OPAT, or itinerary, vaccines and dose numbers for travel, run it for the first week, and count corrections to doses and dates. In the second week, switch on the weekly blood and vaccine course recalls in wai Admin and agree the clinic's rule for GP copies in HIV care.

Read the medico-legal guide to AI scribes before the pilot, and compare other specialties on the specialties hub. The scribe is described on the wai Clinicians page.

Frequently asked questions