AI scribe and clinic software for sleep medicine

The sleep note, scores and studies

A new patient sleep assessment follows NICE's guideline on obstructive sleep apnoea. The physician takes a sleep history when two or more features are present, such as snoring, witnessed apnoeas, unrefreshing sleep or unexplained sleepiness, uses the Epworth Sleepiness Scale in the first assessment, and considers the STOP-Bang questionnaire alongside it, but does not use the Epworth score alone to decide on referral.¹ The draft records each answer, both scores, BMI, neck size, the conditions NICE links to higher prevalence, such as resistant hypertension, type 2 diabetes and atrial fibrillation, and the patient's job and driving.

At follow-up the note is built on device data. NICE advises CPAP for moderate or severe disease, telemonitoring for up to 12 months, a first follow-up within 1 month that reviews telemonitoring data, and annual follow-up once CPAP is optimised.¹ wai does not connect to CPAP devices or the manufacturers' portals. The physician reads the download with the patient, nights used, average hours, residual AHI, leak and pressure, and the draft records each value in its own field. In the US, Medicare's continued coverage asks for a clinical re-evaluation between day 31 and day 91 documenting that symptoms have improved, with objective adherence of at least 4 hours a night on 70% of nights over 30 consecutive days reviewed by the treating practitioner.³ The template holds a field for each, so the note written at that visit carries what the coverage rule asks for.

Insomnia has a different shape. The American Academy of Sleep Medicine makes a strong recommendation for multicomponent cognitive behavioural therapy for chronic insomnia in adults.⁴ Each session note carries the sleep diary summary, sleep efficiency, the time in bed agreed, the stimulus control and cognitive work covered, and the plan for the week.

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 G47.3 Sleep apnoea, G47.0 Disorders of initiating and maintaining sleep [insomnias], F51.0 Nonorganic insomnia and G47.4 Narcolepsy and cataplexy. US practices see ICD-10-CM codes such as G47.33 Obstructive sleep apnea (adult) (pediatric) and F51.01 Primary insomnia. SNOMED CT concepts are suggested alongside, and procedure codes for the sleep study and the device, CPT in the US and OPCS in the UK, stay with the clinic's coder.

The letters a sleep clinic sends, and the driving advice in each

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 sleep medicine that letter explains the study result, the treatment and how to use and clean the device, and sets out the driving advice given in the consultation, with the GP copied.

Driving rules differ by country, and the UK rules are specific. For a car or motorcycle driver, excessive sleepiness from moderate or severe obstructive sleep apnoea, an AHI of 15 to 29 or 30 or more, means the driver must not drive and must notify the DVLA, and licensing later needs control of the condition, improved sleepiness and treatment adherence, with review at least every 3 years. Bus and lorry drivers need review at least annually. Mild apnoea or other causes of excessive sleepiness mean no driving until symptoms are controlled, and the DVLA must be told if control is not reached in 3 months.² The notification is the driver's own, and the letter records exactly what the physician advised. US states set their own rules for drivers with sleep disorders.

Referral letters go to an ENT surgeon, a respiratory colleague or a sleep psychologist, each carrying the question for the specialist and drafted from the whole record. Fit-to-fly letters cover patients travelling with a CPAP device. The structure is in the referral letter, and the overlap with lung disease in AI scribe for pulmonology.

Sleep medicine in the patient's own language

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.

Insomnia therapy is a conversation about habits and thoughts at night, and it works in the language the patient thinks in. CPAP instructions and driving advice need to be understood exactly. The signed note is written in English for the record, or in another language the clinic chooses, and the patient's summary, with the device instructions and the sleep window agreed, can be translated beside it. Crisis and emergency numbers stay exactly as written. The detail is on the multilingual AI scribe page.

Clinic software for sleep medicine clinics, the CPAP cycle on time

A CPAP service is a schedule of returns. In wai Admin, patients request the first follow-up within the month, the mask refit and the annual review 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 annual CPAP review and for the next insomnia session, each approved by a person. Deposits, invoices, payment links and insurer invoices run through the clinic's own Stripe account.

Calls, email, web forms and WhatsApp messages land in one thread per patient, so a message about a sore nose bridge or a leaking mask reaches the team with the history beside it, and replies are drafted in the clinic's voice for a person to approve before they are sent. Insomnia sessions and CPAP reviews can run on video, with the scribe joining the Google Meet, Zoom or Microsoft Teams call. The after-visit companion sends the signed plan home in plain words and tracks each referral, prescription and follow-up until it is done.

Before each review the physician sees a sourced brief of the patient, each fact traced to the letter, result or visit it came from, from the first study to the last download. In the UK, pathology orders go out and results come back through TDL, and private prescriptions are issued and signed through SignatureRx. The full front desk is on the clinic management software page.

One CPAP follow-up, start to finish

Take a 47-year-old sales manager who drives about 30,000 miles a year, diagnosed four weeks ago with severe obstructive sleep apnoea, an AHI of 34 on home respiratory polygraphy, and an Epworth score of 15. He started auto-CPAP and told the DVLA, as advised at diagnosis. At the follow-up the physician reads the download aloud, used on 26 of 30 nights for an average of 5 hours 40 minutes, a residual AHI of 3.1, and high leak most nights. He describes air escaping around a full face mask and a dry mouth. His Epworth score is now 8. They agree a mask refit with a nasal mask and heated humidification, and review in eight weeks.

The draft note holds the history, both Epworth scores, each download value in its field, the mask problem, the plan and the driving advice. The suggested code is G47.3 Sleep apnoea, tied to the line where the diagnosis was confirmed. The physician corrects the residual AHI, which the draft had written as 31, confirms the code and signs.

Two documents go out. The letter to the patient sets out the improvement, the device numbers in plain words, the mask change, and that he should continue the treatment and follow the DVLA's decision on his licence, with a copy to the GP. A patient summary covers mask fitting and cleaning. The front desk sends the booking link for the mask refit, invoices the insurer, and sets the eight-week review and the annual review recall, approved by a person.

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 recalls and the bookings as well as the note.

Sleep medicine is governed by recorded numbers. NICE sets the follow-up points for CPAP,¹ the DVLA sets licensing on control, sleepiness and adherence,² and Medicare ties continued coverage to documented benefit and objective adherence.³ A template with a field for each number makes every follow-up note complete enough for each of them.

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 CPAP follow-ups for one physician. Build the template with fields for nights used, average hours, residual AHI, leak, pressure, the Epworth score and the driving advice, run it for the first week, and count corrections to device values. In the second week add new patient assessments and the insomnia session note, and switch on the one-month and annual review recalls in wai Admin.

Read how to judge AI scribe accuracy before the pilot, and compare other specialties on the specialties hub. The scribe is described on the wai Clinicians page.

Frequently asked questions