Skip to main content

How to Create Your First Clinical Note in Maxly

Updated this week

This guide will walk you through the process of starting a session, capturing a patient conversation, and reviewing the generated note—all in just a few steps.


Step 1: Access Your Clinical Dashboard

  • Log In: Sign in to your Maxly account at https://secure.maxly.vet/en/sign-in.

  • Navigate to the Dashboard: Once logged in, you'll land on your clinical workspace. This dashboard shows your total appointments, patient sessions, and recent activity. As a new user, these stats will update as you start using Maxly.


Step 2: Start a New Clinical Note

  • Click "Create Clinical Note": On the dashboard, find and click the "Create Clinical Note" button to start a new session.

  • Ensure Microphone Access: Maxly will prompt you to enable microphone access if you haven't already. Make sure you've allowed access (see our Troubleshooting Microphone Permission Issues article if you run into issues).

  • Begin the Session: Once the microphone is enabled, Maxly will start capturing your conversation in real-time. Speak naturally during the appointment—Maxly's AI is designed to transcribe veterinary terminology accurately.


Step 3: Capture and Finalize the Conversation

  • Real-Time Transcription: As you speak, Maxly transcribes the conversation, labeling speakers as "Veterinarian" and "Client." You'll see the transcription improve as the session progresses.

  • Pause if Needed: Need a break? Click the "Pause" button to temporarily stop transcription.

  • Finalize the Session: When the appointment is complete, click "Stop Recording" to finalize the session. Maxly will process the transcription and generate a structured clinical note.


Step 4: Review and Save Your Note

  • View the Generated Note: After finalizing, you'll see a structured clinical note with sections like Subjective, Objective, Assessment, and Plan (SOAP). The note is automatically formatted for easy review.

  • Make Edits: Skim through the note and make any necessary adjustments. Maxly learns from your edits to improve future transcriptions.

  • Assign to a Patient:

  • Click "Assign to Patient" to link the note to an existing patient or create a new patient record.

  • Once assigned, the note will appear in the patient's dedicated dashboard, showing key metrics like weight, vitals, and lab results.

  • Export or Copy: Copy the note to your PIMS (Practice Information Management System) or export it as a PDF by using the "Copy Text" or "Export PDF" buttons.


Tips for a Great First Note

  • Speak Clearly: For the best transcription accuracy, speak at a moderate pace and minimize background noise.

  • Use Templates: Apply a preset template (e.g., SOAP) or create a custom one to ensure the note meets your documentation needs. Learn more in our How to Set Up and Use Templates in Maxly article.

  • Attach Supporting Documents: Upload lab results, imaging reports, or referral letters to the Notes and Context section before generating your note. Maxly's AI scribe uses the content of your attachments as additional context when drafting your note—giving you a more informed starting draft to review. Supported file types include PDFs, Word documents, text files, and images. Learn more in our How to Upload and Use Document Attachments in Maxly article.

  • Explore Insights: Check the "Insights" section on the note page for AI-generated observations and follow-up suggestions specific to the appointment.


Want to See It in Action?

Watch our demo video to see how Maxly creates clinical notes in real-time: Watch the Maxly Demo. You can also try a demo note to practice—see our Trying a Demo Note in Maxly article for details.

Ready to create your first note? Log in at https://secure.maxly.vet/en/sign-in and get started. For help, email us at hello@maxly.vet or book a demo.

Did this answer your question?