Document
Keep your attention on the care encounter.
Record the conversation and clearly state your own findings and agreed actions.
Hysio Internal Medicine
AI Voice-Driven Reporting for internists
Hysio organises an outpatient consultation, a follow-up dictation or a contact during admission into a source-bound internal medicine report, with conclusion and management kept separate.
Spoken care information from your care encounter
Internal medicine
A structured report in your professional terminology
From care encounter to report
You work. Hysio documents.
Hysio turns spoken information into a report. Choose the report format for the conversation you are documenting.
AI assistants
Suited to your work.
- Hysio Internal Medicine Consultation
- Hysio Internal Medicine Intake
- Hysio Internal Medicine SOAP Note
You stay in control of what gets saved.
In your workday
How Hysio fits into your workday
More attention for the conversation, less typing afterwards.
-
You document the conversation
State relevant information, your own findings and agreed actions aloud so you can find them in your report.
-
Hysio creates your report
The information appears under the headings of your chosen report format, so you can review each section.
-
You review and copy the report
Check names, facts and agreed actions. Edit the text where needed before using the report in your records.
Try it yourself
Experience what Hysio can mean for your work.
Try Hysio free for 14 days or schedule a personal demo.
- No credit card needed
- Cancel any month
- GDPR-compliant, data hosted in the EU
Profession
Hysio Internal Medicine
For your team
Share with a colleague
Quick answer Internal medicine documentation for each contact 50 questions with cited sources
Quick answer
Documentation for internal medicine
A profession-specific structure for care in which several conditions, results and treatments come together, with a dedicated place for the source, findings, your conclusion and the agreed management.
Read how Hysio works in an outpatient consultation, a follow-up dictation or a contact during admission.
- What is voice-driven reporting for internists?
- Voice-driven reporting, also known as an AI scribe: Hysio turns what was said in an outpatient consultation with lab results into a report. It is also called AI documentation. For internal medicine there are three documentation formats: Internal Medicine Consultation, Internal Medicine Intake and Internal Medicine SOAP Note. [2] [3] [4]
- What stays tied to the source?
- In multimorbidity, Hysio keeps history, results, the client's account, your assessment and the agreements each separate, and only includes them when they were said or supplied. That keeps admin with AI in the internal medicine clinic close to the conversation. [1] [10]
- Who determines the content?
- You, as the internist. You check results, medication and management plan before you save the report. [1] [8]
- How does the report keep several conditions together?
- The structure follows organ systems and related medical information. Hysio is built to be the most reliable help with multimorbidity: every item you mention keeps its source, you check the report, and the medical judgement stays with you and your team. [1] [10] [9]
- Profile code 031
- Documentation formats 3 profession-specific documentation formats: Hysio Internal Medicine Consultation, Hysio Internal Medicine Intake, Hysio Internal Medicine SOAP Note.
- Source focus organ systems and interrelated medical information
- Record boundary you check section by section
Voice-driven reporting in internal medicine
Which internal medicine documentation format suits a consultation in which laboratory results are discussed? #
That depends on the contact, not on the result itself. An outpatient conversation or a follow-up dictation suits the internal medicine consultation report, a first broad conversation suits the intake, and a short follow-up contact or a contact during admission suits the progress note. In all three, a result is placed verbatim from the source under additional investigations, with test name, value, unit and time of measurement. Your own conclusion stands apart from it, under Conclusion. [2] [3] [4] [1] [10]
How do you organise the history and the medication discussed in an internal medicine report? #
The history gets its own section, in reported speech and in the words of the source. Medication that was discussed in substance during the conversation comes back verbatim from the source in the narrative block where it belongs. Hysio does not turn it into a medication list, does not normalise any dosage and does not touch the fixed blocks of your own record system for active medication, allergies and adverse reactions. That way it stays visible what was discussed, without it becoming a second overview alongside what is already registered. [2] [1] [9]
How does an internal medicine report fit the record pathway of your own hospital? #
Hysio delivers text per section; you paste it into the route your department already uses. Active problems and diagnoses stay where you record them now, because Hysio does not assign any record structure itself. Coding also remains your work: the report fills in no diagnosis code, no procedure code and no care product. That way nobody has to set up the record again. [9] [1] [2]
Which personal data does Hysio remove from an internal medicine report? #
Names are replaced by the role: the patient, the internist, the GP or the radiologist. Addresses, citizen service number, patient number, document number and registration codes of healthcare professionals are left out entirely, including in titles, quotations and source labels. A specific location becomes a general term such as home, work or hospital. What remains is the content this contact carries, and not everything that is known about someone. [7] [10] [1]
Do you pay for voice-driven reporting per internal medicine consultation? #
Hysio's price is on the central pricing page and does not differ per specialty. Internal medicine pays the same as any other field: you pay for the subscription, not per report and not per documented item. The number of conditions or results within one contact does not change that either. See the pricing page for the current overview per type of plan. [5] [6]
When does your own template suit better than an internal medicine documentation format from Hysio? #
Your own template suits better when your specialty group already uses an established layout that everyone reads from and on which agreements are built. Weigh that against the internal medicine sections, in which source, finding, conclusion and management are already separated. Bear in mind that introduction in a hospital usually runs at institutional level, through procurement and a data processing agreement, and not at specialty group level. Discuss that consideration briefly with your team before you choose. [1] [9] [10]
How do you check an internal medicine report against the dictation and the supplied source? #
Read the report next to the source and check specifically for date, value, unit, side, abbreviation and result. Hysio does not resolve any abbreviation itself and does not fill in any missing value, so a discrepancy almost always points back to the source or to the dictation. Also pay attention to what is not there: silence is not a finding, so something that was not mentioned must not appear anywhere as normal, absent or ruled out. That way you prevent an assumption from standing as an established fact. [1] [10] [8]
How do you keep your attention on the patient during an internal medicine consultation? #
Hysio follows the conversation, so during the contact you can look at the patient instead of at your screen. What the patient or a relative says is recorded as their report in reported speech, not as your finding. The results and your own findings are in other sections, so the patient's story does not get buried under the numbers. You only finalise the report after you have checked it against the source. [1] [2] [9]
What makes voice-driven reporting with Hysio different from a dictation you write up yourself? #
Hysio organises, but does not add any clinical synthesis. The consultation report and the progress note carry source content only; only the intake report has a separate section at the bottom for limited considerations of its own, clearly apart from your conclusion. A supplied investigation report also keeps its own conclusion with modality, date and source label, separate from the conclusion you state. That separation between organising and assessing remains the guiding principle in every contact. [1] [2] [9]
How does a specialty group get started with internal medicine documentation in Hysio? #
Start with one contact type, for example the outpatient follow-up consultation, and not with your entire clinic day. Agree in advance who reviews the report and who puts it in the record. Arrange the institutional side in good time, because procurement and the data processing agreement in a hospital usually run outside the specialty group. Only expand once that first round proves reliable. [6] [7] [1]
Documentation formats for internists
When do you choose the Internal Medicine Consultation? #
Hysio Internal Medicine Consultation is intended for an outpatient conversation or a follow-up dictation. The format sets out reason for attendance and referral, past medical history, focused history, physical examination, additional investigations, conclusion, considerations and management as separate sections. The conclusion carries only what you have stated; if you do not state one, that section stays empty and shows a fixed sentence. Saving always waits for your own assessment. [2] [1] [10]
What do you record in the Internal Medicine Intake at a first conversation? #
Hysio Internal Medicine Intake is intended for the first broad outpatient conversation. In addition to the sections of the consultation report, this format has room for active diagnoses, social history and the patient's expectations. At the bottom there is one separate section for limited considerations of Hysio's own, so that these never become mixed with your conclusion. [3] [1] [10]
When is an Internal Medicine SOAP Note enough? #
Hysio Internal Medicine SOAP Note is intended for a short follow-up contact or a moment of contact during admission. The format delivers a progress note according to Subjective, Objective, Assessment and Plan, with the course since the previous contact. Here, that structure is a way of ordering the progress note and not a documentation standard prescribed by the profession for internal medicine. Here too, the Assessment carries only your own judgement. [4] [1] [10]
How do you choose between the three internal medicine documentation formats? #
The appropriate report structure follows the contact type and not the topic: a first broad conversation calls for the intake, an outpatient conversation or follow-up dictation for the consultation report, and a short contact during admission for the progress note. The content does not shift with that choice: in every format, report, finding, external report, intention and completed action remain separate source roles. If in doubt, the appropriate report structure is the one that allows the most detail. [1] [2] [10]
When do you choose an intake and when a follow-up report? #
Choose the intake when there is not yet a documented starting point: that format describes the baseline situation in full, including past medical history and social context. If that starting point does exist, a follow-up report shows the change since the previous contact. Hysio does not calculate that difference itself; a course is only included when the source states it. That way the difference between baseline situation and change remains traceable. [1] [2] [10]
Which details about a procedure belong in the report when the source is mixed? #
Describe the reason, the procedure and the findings as they were supplied, with the source role attached. If, according to the source, an investigation was carried out but no result was stated, Hysio records that the result has not been documented, instead of assuming one. An announced investigation remains an intention, and details the source does not mention are not added. [1] [2] [10]
Which source information belongs in an internal medicine handover? #
Keep the handover to what the recipient needs: the situation, the background, your assessment and the requested follow-up. That structure fits the national quality standard for in-hospital emergency care (Kwaliteitsstandaard Intramurale Spoedzorg), which recommends a standardised handover. Make it visible who the source is and who the recipient is, and keep your assessment separate from what someone else has established. Hysio never assumes consent; only an explicitly stated agreement goes into the text. [1] [2] [10]
How do you separate what the patient says from what you establish in the report? #
The report keeps five source roles apart: what the patient or a relative reports, your own finding or conclusion, the statement of a referrer or another investigation report, a plan or intention, and a demonstrably completed action. These reports are in reported speech and therefore read as reports, not as findings. An intention is never presented as completed. That way you prevent an opinion from being read as an established fact. [1] [2] [10]
How do you compare findings between two internal medicine contacts? #
Only compare when both values and both times of measurement are literally in the source. Hysio calculates no difference, no decrease and no percentage: the report states the two values with their dates and leaves the interpretation to you. Beyond that, only name changes that were actually discussed or supplied, and if in doubt, leave what is there. A short comparison is more valuable than a long, uncertain list. [1] [2] [10]
How do you document a results conversation with the patient? #
Record which result was discussed, with modality or test name, date and source label. A supplied investigation report keeps its own conclusion; the Conclusion section carries only yours, and the two are never merged. The explanation to the patient and the agreed follow-up get their own place, apart from the result itself. That way it stays clear when each step was actually taken. [1] [2] [10]
Lab results, medication and multiple conditions
How do you describe the history of an internal medicine consultation? #
Record the request for care, the course of symptoms and the context in the words of the source, in reported speech and without a summarising interpretation placed before it. Whatever comes up about medication is only in the report when it was discussed in the conversation, and then verbatim from the source. Words of uncertainty such as possibly or probably stay in, because they belong to what was said. That way the distinction between the request for care and your own interpretation stays sharp. [1] [10]
How do you record who supplied information about the past medical history? #
Record the origin of each detail: the patient, a relative, the referrer or a supplied investigation report. Names disappear from the text in the process; what remains is the role, such as the GP or the radiologist. That way the past medical history stays traceable and a colleague can later ask where a detail came from, without it being read as your own finding. [1] [10]
How do you record laboratory results and scores with their time of measurement? #
A result comes back as a whole: test name, value, unit and time of measurement, literally as the source supplies them. Hysio does not calculate any score itself and does not derive one either, so a kidney function, a comorbidity index or a severity score is only included when you have established or dictated it. Decimal separators, units and date formats remain unchanged, even when they differ from one another within a single report. [1] [10]
How do you link a result to the investigation and to your assessment? #
The result is under additional investigations, with the investigation, the date and the source attached. Your assessment is under Conclusion and the follow-up under Management. Those three sections do not merge into one another, not even when they concern the same finding. That way it stays clear which part is source and which part is interpretation. [1] [10]
Does Hysio assess imaging itself? #
Hysio includes a supplied radiology report with modality, date and source label, but does not assess any scans, X-rays or other images itself. The radiologist's conclusion stays within that investigation report and does not move to your conclusion. If the source gives no conclusion, Hysio does not fill one in. That way the assessment of the image stays with the radiologist. [9] [8] [10]
How does an internal medicine report handle abbreviations? #
An abbreviation is taken over as it was dictated: Hysio does not write it out and does not introduce any of its own. That prevents an incorrectly resolved abbreviation from ending up in the record as an established fact. Agree within your specialty group which spelling you use and record that once, so that colleagues outside your own specialty can also read the text. [1] [10]
How do you record information supplied by a relative or the referrer? #
State explicitly who supplied it: the patient, a relative or the referrer. An incoming referral question may be recorded as an attributed source fact, but Hysio does not derive any route, indication or urgency from it itself. Consent to share that information is never assumed; only an explicitly stated agreement goes into the text. That way it stays traceable who was allowed to share which information. [1] [10]
What does a co-treating clinician need from your internal medicine report? #
Make it visible which discipline supplied a finding and who takes up the follow-up, so nobody has to guess. Also state whether the text was produced under supervision, because an internal medicine report can come from an internist as well as from a doctor in training. Keep the wording readable for colleagues outside your own specialty and keep each finding with its own source. [1] [2] [10]
What does a useful example of an internal medicine report look like? #
A useful example shows a real contact: what was said, which findings were mentioned, which conclusion the internist stated and which management was agreed. Do not invent a diagnosis the source does not mention, and only show a result when it was actually discussed. Such an example immediately shows where the boundary between source and interpretation lies, and is therefore also suitable for onboarding new colleagues. [1] [10] [2]
How much information do you share in a handover about an internal medicine patient? #
Share what the purpose of that handover requires, and not the entire record. Professional confidentiality also applies within the hospital, so the recipient receives the data needed for the care they take over. The rest stays in the record, where it is kept in line with the statutory retention period. That way the handover stays short, focused and traceable. [9] [7] [10]
Sources, privacy and boundaries in internal medicine
Does Hysio make a diagnosis itself in the internal medicine report? #
No, Hysio organises the source and does not establish any diagnosis, indication or urgency. The Conclusion section carries only what you have stated; if you do not state a conclusion, that section stays empty and shows a fixed sentence, instead of a working hypothesis Hysio makes up. A classification or stage is also only included when the source mentions it. That boundary applies no matter how convincing a pattern seems. [8] [1] [10]
Who is responsible for what ultimately goes into the record? #
You, as the treating internist. Hysio delivers a report for your review and does not take over any professional decision. The report also never claims that anything has been saved, sent, shared or removed; you take that step in your own record system. As long as you have not released the report, it is supporting material and not a record entry. [1] [8] [10]
What happens if a detail is missing from the source? #
Then the section does not stay blank, but receives the fixed sentence that belongs to that section. If there is partial information, the usable part goes into the report and what is missing is named specifically. Hysio does not fill in any date, value or conclusion and never writes that something is normal, absent or ruled out merely because it was not mentioned. A blank line can unintentionally look like a statement that is not there. [1] [8] [10]
Can you use Hysio when the situation is acute? #
In an acute situation, you assess it yourself, at the bedside: Hysio does not triage and does not determine urgency. A report records afterwards what you saw, concluded and agreed. An outgoing referral is also only included when you have stated it; Hysio does not derive one itself from a complaint, age or a missing detail. Documentation always follows the clinical decision, never precedes it. [8] [7] [10]
Who may receive information from an internal medicine report? #
That is determined by the purpose of sharing and the legal basis that applies to it, not by how easy it is to forward. Within the treatment relationship you share what a colleague needs for the care they take over; outside it, an explicitly stated agreement is needed. Hysio never assumes that agreement and only records it when it is in the source. That way you prevent sensitive information from going further than necessary. [7] [10] [1]
Does Hysio draw up a management plan or a treatment proposal itself? #
No, the Management section carries only what you have agreed. Hysio does not propose any medication or change, does not normalise any dosage and does not fill in treatment limits on the basis of age or diagnosis. An agreement about treatment limits is only included when it has been stated. That way it stays clear who filled in which part of the text. [8] [9] [10]
How is uncertainty about a finding reflected in the report? #
Markers of uncertainty stay in: probably, possibly or to be assessed do not disappear from the text. A differential diagnosis keeps the order you stated, because that order carries meaning. Hysio never makes a finding more definite than the source allows and leaves an open question as an open question. That way a reader immediately knows how certain a finding is. [1] [10] [8]
What happens when two sources contradict each other? #
Then Hysio does not choose. Both readings remain, each with the source it comes from, and the report makes it visible that verification is needed. A clear later correction does replace the detail that was directly corrected, and nothing else. The choice between two readings therefore remains your assessment, with both readings still visible. [1] [10]
How do medication and measured values end up in the report? #
Exactly as they were dictated. Substance name, form, strength and frequency are not rewritten, and a decimal separator, unit or date format is not made uniform. What was discussed in substance about medication comes back as narrative with the source role attached and not as a list. Your interpretation of those values is in a different section. That way, voice-driven admin keeps the raw measurement separate from your own interpretation. [1] [10] [8]
What do you check last before you save the report? #
Go through the sections once in a fixed order and ask yourself for each section whether every date, value, unit, side and abbreviation matches the source. Then check whether your conclusion stands apart from the conclusion of a supplied investigation report, and whether every statement still carries the source role it came in with. Correct what differs and only then save. A short final look prevents most errors afterwards. [1] [7] [8] [10]
Introduction and daily use
How do you prepare a shift handover with an internal medicine report? #
Agree who reviews the report before it goes into the handover. Include what the colleague on duty needs to be able to continue: the situation, the background, your assessment and the outstanding actions with a name attached. Leave the source roles in place, so the recipient sees what the patient reported and what you established. That way the recipient immediately knows what is relevant and what is not. [9] [7] [10] [2]
Which agreements on lab results and medication do you make in advance within your department? #
Record which documentation format belongs to which contact type, who reviews the report and who ultimately approves it. Also agree how you handle a report that was produced under supervision, so that the attribution is correct. Keep that agreement short and on paper, so that a new colleague can read it in one go. Review that agreement once the team has gained experience with it. [1] [2] [9]
How do you set up a small trial with one multimorbidity clinic session? #
Take one contact type and one week, instead of the entire outpatient clinic straight away. During that round, collect the corrections you make and look at where they come from: the source, the dictation or the structure. Only expand once the same corrections no longer come back. That way the first trial stays manageable and easy to oversee. [6] [7] [1]
How do you adapt an internal medicine report to the agreements of your own department? #
Put the sections next to the headings your department already uses and adjust the order where necessary. In doing so, follow the national agreements on correspondence with the GP, because they determine what a referrer expects back. Have the designated colleague check the adjustment before you introduce it more widely. That way the text fits how your department already works. [9] [1] [10]
How do you dictate a consultation with many lab results? #
First state the reason for the visit and what the client tells you. Then read out the results with their dates, and say separately what you make of them. That is voice-driven reporting: Hysio puts measured values and your interpretation in different sections. Hysio records medication as you state it. [1] [10] [2]
How do you measure whether Hysio saves time in consultations with many results? #
Measure it yourself, within your own specialty group, and always compare the same kind of contact with the same kind of contact. Add dictating, reviewing and correcting together, because the first step alone says nothing. There is no national figure on administrative time measured specifically for internists, so do not rely on a general percentage. Give the quality of the report more weight than the time gained on the clock. [1] [9] [6]
Which conditions apply during the trial period for an internal medicine clinic? #
Hysio's trial conditions are described centrally and apply equally to every field; there is no separate arrangement for internal medicine. Use that period to judge whether an internal medicine report fits your own contacts. Also arrange the institutional side in good time, because in a hospital that runs through procurement and a data processing agreement. Report any uncertainties during the trial directly to your contact person. [6] [5] [7]
Where can you find the pricing and terms for an internal medicine department? #
The prices are on the pricing page and the privacy and legal information on the legal pages; both apply across the platform. Do not turn those general terms into a professional standard: the duty to keep records, the retention period and professional confidentiality follow from the law and from your own professional rules, not from a supplier's terms. Those pages are updated regularly, so consult them directly. [5] [7] [8]
How do you keep abbreviations for lab values consistent within your department? #
Agree which spelling you use for frequently used terms and abbreviations, and record that list once. Hysio does not write out abbreviations, so that list determines how colleagues read them, not the report. Keep the text understandable for colleagues outside your own specialty and review the list whenever new abbreviations are added. [1] [9] [10]
How do you structure a case with several conditions? #
Split first by contact and then by source role, instead of putting everything in one block. Several conditions side by side make the report longer, not different in structure: finding, conclusion and management remain separate. Hysio does not add a summarising conclusion that the source does not mention, not even when the pattern seems obvious. That way a complex case stays traceable despite its size. [1] [10] [2] [8]
Sources
- 1 Hysio: Beroepsprofiel de interne geneeskunde (interne Hysio-documentatie) Document date: 2026-08-09 Accessed on 2026-08-31
- 2 Hysio: Hysio Internistisch Consult (interne Hysio-documentatie) Document date: 24 augustus 2026` (herzien 25 augustus 2026) Accessed on 2026-08-31
- 3 Hysio: Hysio Internistische Intake (interne Hysio-documentatie) Document date: 24 augustus 2026` (herzien 25 augustus 2026) Accessed on 2026-08-31
- 4 Hysio: Hysio Internistisch SOEP-Verslag (interne Hysio-documentatie) Document date: 26 augustus 2026 Accessed on 2026-08-31
- 5 Hysio: Actuele Hysio-prijzen (interne Hysio-documentatie) Document date: 2026-08-26 Accessed on 2026-08-31
- 6 Hysio: Actuele proefperiode (interne Hysio-documentatie) Document date: 2026-08-31 Accessed on 2026-08-31
- 7 Hysio: Hysio Privacyverklaring (interne Hysio-documentatie) Document date: 2026-07-16 Accessed on 2026-08-31
- 8 Hysio: Hysio Disclaimer (interne Hysio-documentatie) Document date: 2026-07-16 Accessed on 2026-08-31
- 9 Hysio: Hysio en medische dossiersystemen (interne Hysio-documentatie) Document date: 2026-07-16 Accessed on 2026-08-31
- 10 Overheid: Wet op de beroepen in de individuele gezondheidszorg (Wet BIG), art. 3, 14, 36 Document date: 2026-08-04 Accessed on 2026-08-04
- 11 KNMG: Herregistratie-eisen medisch specialisten Document date: 2026-08-04 Accessed on 2026-08-04
- 12 NZa: Passende bekostiging MSZ Document date: 2026-08-04 Accessed on 2026-08-04
- 13 Nictiz: eOverdracht Document date: 2026-08-04 Accessed on 2026-08-04
- 14 Overheid: Burgerlijk Wetboek Boek 7, art. 7:454 (dossierplicht, bewaartermijn), art. 7:457 (beroepsgeheim), art. 7:448/7:451 (informed consent) Document date: 2026-08-04 Accessed on 2026-08-04
- 15 KNMG: KNMG-richtlijn Omgaan met medische gegevens Document date: 2026-08-04 Accessed on 2026-08-04
- 16 NHG en FMS (kerngroep met NIV-vertegenwoordiging): Richtlijn Informatie-uitwisseling tussen Huisarts en Specialist (HASP) Document date: 2026-08-04 Accessed on 2026-08-04
- 17 Dertien wetenschappelijke verenigingen (waaronder NIV en Nederlandse Vereniging voor Heelkunde, NVVH; overige elf: NVA, NVK, NVKG, NVN, NVOG, NVSHA, NVSHV, NVVC, NVVP, NVVR, V&VN): Kwaliteitsstandaard Intramurale Spoedzorg Document date: 2026-08-04 Accessed on 2026-08-04
- 18 Nictiz: LOINC en Nederlandse Labcodeset Document date: 2026-08-04 Accessed on 2026-08-04
Hysio creates the report. You remain responsible for what you save in the record.