For LPN / Charge Nurse (SNF)s ·
What you'll accomplish
By the end of this guide, you'll be able to speak your clinical observations at the bedside or immediately after care — and get back formatted nursing documentation. Instead of reconstructing what happened from memory at the end of a 12-hour shift, you capture it in real time while the details are fresh.
What you'll need
What you should see: A simple recording interface — a large microphone button in the center of the screen.
Troubleshooting: If you can't find DAX Express, search for "Dragon Medical One" or "Nuance Medical" — the naming has evolved. The free tier app is specifically "DAX Express."
DAX is designed for healthcare professionals dictating clinical notes. You speak naturally — describing what you observed, what you did, what the patient said — and it transcribes and formats the content into clinical documentation. Unlike general voice transcription, it understands clinical terminology (vital signs notation, anatomical terms, medication names, nursing assessment language).
At your next clinical encounter, after assessing a resident, tap the microphone button and speak:
"Patient is a 76-year-old male with CHF, complaint of increased shortness of breath since this morning. Assessment: respiratory rate 24, O2 saturation 90% on room air, bilateral lower lobe crackles on auscultation, 2-plus pitting edema bilateral lower extremities. Patient positioned in high Fowler's. Physician notified at 9:45 AM. Orders received for 40 milligrams furosemide by mouth. Medication administered at 10:10 AM. Patient reports improved breathing at noon, O2 sat 96% on 2 liters nasal cannula."
Tap the stop button. DAX will process for a few seconds.
What you should see: A transcribed, formatted clinical note using proper nursing documentation style — ready to copy and paste into PointClickCare.
After DAX generates the formatted note:
Vital signs narrative: "Vital signs obtained at [time]: BP [X/X], HR [X], RR [X], temp [X], O2 sat [X percent] on [room air/oxygen]. Resident is [description]."
Medication administration note: "Administered [medication] [dose] by [route] at [time] for [indication]. Resident [tolerated well / reported side effects / etc.]."
Shift assessment note: "Shift assessment completed at [time]. Resident is alert and oriented to [X], skin warm and dry, [system-by-system brief findings]. No acute distress noted."
Family contact note: "Family contact made at [time]. Spoke with [relationship] who was [notified of / calling about]. Information provided: [what was said]. Family [response]."
Physician call documentation: "Physician [name] notified at [time] regarding [clinical concern]. SBAR communicated. Orders received: [orders]. Orders implemented at [time]."