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AI Clinical Documentation

Document Smarter. Care More.

Your AI Clinical Documentation Teammate listens during patient encounters, generates structured clinical notes in real time, suggests accurate codes, and ensures quality measures are captured — so clinicians can focus on patients, not paperwork.

HIPAA Compliant SOC 2 Type II Fully Auditable
What This Teammate Does

End-to-End Clinical Documentation — Fully Automated

From ambient capture during the patient encounter to finalized, coded notes ready for billing, your AI teammate handles every documentation step with clinical precision.

Ambient Documentation

Listens to provider-patient conversations and automatically generates structured clinical notes — capturing history, exam findings, assessments, and plans without manual dictation.

Coding Suggestions

Analyzes clinical narratives and suggests ICD-10, CPT, and E/M codes in real time — improving coding accuracy and reducing downstream denials and compliance risk.

Quality Measure Reporting

Automatically identifies and captures quality measures, HEDIS gaps, and value-based care metrics during documentation — ensuring nothing falls through the cracks.

Note Summarization

Summarizes lengthy patient records, prior visit notes, and referral documents into concise, actionable summaries — saving clinicians valuable review time before each encounter.

Template Management

Maintains and adapts specialty-specific note templates that evolve with clinical workflows — ensuring consistent structure while accommodating provider preferences.

Compliance Documentation

Ensures every note meets regulatory requirements for medical necessity, payer-specific documentation standards, and audit readiness — reducing compliance risk automatically.

Who It's For

Built for Healthcare Leaders Driving Clinical Efficiency

Designed for the executives and clinical leaders responsible for documentation quality, clinician satisfaction, and operational performance.

Chief Medical Officers

CMOs focused on reducing clinician burnout, improving note quality, and ensuring documentation supports value-based care initiatives and patient safety.

  • Reduce documentation burden by 50%+
  • Improve clinical note completeness
  • Support quality measure capture

VP of Clinical Informatics

Informatics leaders responsible for EHR optimization, clinical workflow design, and technology adoption who need tools that clinicians actually want to use.

  • Seamless EHR integration
  • High clinician adoption rates
  • Measurable workflow improvement

Physician Leaders

Department chairs, medical directors, and practice leaders who want to give their physicians time back while maintaining documentation excellence and compliance.

  • Eliminate after-hours charting
  • Increase patient face time
  • Standardize documentation quality
What It Replaces

Replace Manual Charting with Ambient Intelligence

AI Clinical Documentation directly displaces time-consuming, error-prone manual documentation — without changing how clinicians interact with patients.

Traditional Model
AI Teammate
Manual note typing after visits
Ambient real-time note generation
Outsourced medical transcription
Instant AI-generated documentation
Manual coding by coders/CDI staff
AI-suggested codes at point of care
Retrospective quality measure capture
Real-time quality gap identification
After-hours pajama-time charting
Notes completed before patient leaves
Measurable Impact

KPIs That Move the Business

Every AI Clinical Documentation deployment is benchmarked against the metrics that matter most to healthcare organizations.

2+ hrsSaved per Clinician per Day

Clinicians reclaim over two hours daily previously spent on manual documentation, translating to more patient encounters or improved work-life balance.

95%Coding Accuracy

AI-suggested codes achieve 95% accuracy, reducing downstream denials and improving revenue capture from the point of care.

40%Less After-Hours Documentation

Dramatic reduction in after-hours charting directly improves clinician satisfaction, reduces burnout, and lowers turnover.

3xFaster Note Completion

Notes are generated and ready for review in seconds rather than minutes — most finalized before the patient leaves.

↑30%Quality Measure Capture

Automated identification of quality gaps during encounters significantly improves HEDIS and value-based care performance.

90%+Clinician Adoption Rate

Ambient design requires zero behavior change from clinicians, driving adoption rates that traditional tools cannot match.

Seamless Integration

Connects to Your Existing Clinical Systems

Your AI teammate integrates with the EHR, dictation, and coding systems you already use — no rip-and-replace required.

Epic EHR

Native integration with Epic for note creation, order entry, problem list updates, and seamless documentation workflows.

Cerner / Oracle Health

Bi-directional sync with Cerner for clinical documentation, coding workflows, and real-time patient chart updates.

Dragon / Nuance

Complements and enhances Dragon Medical with ambient AI capabilities that go beyond traditional dictation workflows.

Coding Engines

Integrates with 3M, Optum, and other coding platforms to deliver AI-suggested codes directly into coding workflows.

Quality Reporting Platforms

Connects to quality reporting and registry systems for automated measure capture and submission workflows.

API & FHIR Support

FHIR-native APIs and configurable webhooks for any system not covered by out-of-the-box connectors — fully extensible.

Deployment Timeline

Live in Weeks — Not Quarters

A structured, phased deployment that delivers measurable results from the first sprint. No multi-year transformation required.

Week 1–2

Discovery & Configuration

  • Map clinical documentation workflows by specialty
  • Configure EHR integrations (Epic, Cerner, etc.)
  • Define note templates and coding rule sets
  • Set up HIPAA controls and audit logging
Week 3–4

Pilot Launch & Validation

  • Deploy with a pilot group of clinicians
  • Clinician review and feedback on generated notes
  • Benchmark: time saved, coding accuracy, note quality
  • Refine models based on specialty-specific feedback
Week 5+

Scale & Optimize

  • Expand to additional specialties and care settings
  • Continuous model improvement from clinician feedback
  • Onboard remaining departments and providers
  • Quarterly reviews with documentation quality benchmarks
Governance & Trust

Enterprise-Grade Security for Clinical Environments

Every note is auditable. Every action is governed. Built from the ground up for HIPAA-regulated healthcare environments.

Clinician-in-the-Loop by Default

Every generated note is presented for clinician review and approval before finalization. AI assists — clinicians decide.

HIPAA Compliant & Audit-Ready

Full audit trails, BAA coverage, role-based access control, and compliance logging designed for healthcare regulatory audits.

Data Residency & Encryption

PHI encrypted at rest and in transit with AES-256, configurable data residency, and strict retention policies.

Works With Your EHR

Native integrations with Epic, Cerner, and other EHR platforms via secure APIs and certified app marketplace.

Get Started in 30 Days

Launch Your AI Documentation Pilot

See measurable results — reduced documentation time, higher coding accuracy, and happier clinicians — within your first month. No multi-year commitment. No rip-and-replace. Just results.

Live in 2–4 Weeks HIPAA Compliant Clinician-in-the-Loop No Data Lock-in