Clinical Documentation AI

The Challenge

A multi-specialty medical group with 180 providers was drowning in documentation. Clinicians spent more time on notes than on patient care, leading to burnout, after-hours "pajama time" documentation, and provider turnover.

The documentation burden was crushing:

• 2+ hours daily spent on clinical documentation
• 45% of providers doing notes after hours regularly
• Note completion backlog averaging 48 hours
• Copy-paste propagation of outdated information
• Provider burnout cited as top concern in surveys

"I became a doctor to help patients, not to type notes. On my worst days, I spend more time with my keyboard than with the people I'm supposed to be caring for."

— Family Medicine Physician

The Solution

We deployed an AI documentation assistant that captures clinical conversations, structures the information, and generates draft notes for provider review.

flowchart LR
    Conversation[Visit] --> AI[AI Processing]
    AI --> Draft[Draft Note]
    Draft --> Review[Provider Review]
                

Ambient Documentation

With patient consent, the system captures the clinical conversation and extracts relevant information:

• Chief complaint and history of present illness
• Review of systems responses
• Physical exam findings as verbalized
• Assessment and plan discussion
• Patient education and questions

Intelligent Structuring

The AI structures extracted information into proper note format:

• Maps content to appropriate note sections
• Reconciles with existing patient data
• Flags inconsistencies for provider review
• Applies specialty-specific formatting

Provider Control

Every note is a draft that requires provider review and attestation:

• Clear visual indication of AI-generated content
• Easy editing and correction interface
• Provider sign-off required before finalization
• Feedback loop improves future suggestions

Results

After 6 months of deployment:

• 2.5 hours saved per provider per day on documentation
• 78% reduction in after-hours documentation time
• 96% accuracy on AI-generated note content
• 48-hour backlog reduced to same-day completion
• +31 point improvement in provider satisfaction
• Provider turnover decreased 40% year-over-year

"I finish my last note before I leave the office now. I haven't done documentation at home in three months. I have my evenings back."

— Internal Medicine Physician

Technical Details