Clinical Documentation Agent
An agentic AI that structures clinical notes and drafts coding recommendations — HIPAA-aligned.
The problem we were asked to solve
Clinicians spent hours on documentation each day, coders faced backlogs, and revenue integrity teams had limited time for audits. Unstructured notes made downstream analytics unreliable, and inconsistent coding led to denied claims and rework.
What we built
An agentic AI documentation assistant that listens to ambient encounter audio (with consent), structures the note into problem/assessment/plan sections, links each finding to the underlying evidence and drafts coding recommendations (ICD-10/CPT). Clinicians review and approve — nothing ships without a human in the loop.
How it works, end to end
A grounded, secure and auditable pipeline built for enterprise scale.
Ambient audio (with patient consent) or dictation ingested through a HIPAA-aligned secure pipeline.
Medical-grade ASR converts audio to text with speaker attribution.
An LLM agent structures the note into SOAP sections and extracts diagnoses, procedures and vitals.
Findings are linked back to the transcript and to prior chart data for traceability.
Coding agent proposes ICD-10 / CPT codes with rationale and confidence levels.
Clinician reviews, edits and signs; approved output syncs to the EHR with full audit history.
The stack behind the outcomes
Impact delivered
- Meaningful reduction in per-encounter documentation time for clinicians
- Structured, analytics-ready clinical data across specialties
- Faster coding cycle with fewer denials from missing documentation
- Better clinician experience and reduced after-hours charting
- Governance framework that scales safely across facilities