AI-powered engine transforming clinical encounters into documentation
The Documentation Engine processes clinical encounters into structured documentation. It transcribes and diarizes audio files, identifying who said what during the visit. Processing typically completes within 30-90 seconds for complex audio.
The engine pulls in all relevant context about the patient and episode before processing new material. When audio, images, or manual entries arrive, the system reconciles this new information with existing data to produce structured documentation output.The engine maintains the full episode history—every visit, medication change, assessment, and intervention from admission to present. It correlates current responses with all previous information to maintain an accurate, consistent picture of the patient. If a patient says they’re taking a medication that wasn’t documented last visit, the system flags it. If today’s pain level contradicts yesterday’s assessment, it’s caught.
Audio arrives from the mobile app and enters the transcription service, which produces speaker-separated text. The diarization identifies whether the clinician, patient, or family member is speaking. This transcript then flows through the inference engine along with any uploaded images and the complete patient context.The engine applies OASIS logic, Medicare requirements, and organization-specific rules to structure the raw information into compliant documentation. It determines which forms need completion, what assessments are required, and how to format the output for your specific EMR.
Built into the processing pipeline are quality checks and scrubber rules. The engine validates documentation against regulatory requirements, checks for clinical consistency, and ensures all required fields are complete. These checks happen during processing, not after, preventing errors from reaching the clinician review stage.The system applies your organization’s specific documentation rules—terminology preferences, required fields, custom validations. If your agency requires specific wording for Medicare compliance or has particular documentation standards, the engine enforces these automatically.
The final output is structured JSON that maps directly to your EMR’s documentation requirements. Each piece of documentation includes metadata about its source (transcript quote, image reference, inference from context) and which clinical guidelines informed its generation. This structured data feeds into forms, narratives, OASIS assessments, and any other documentation format your organization requires.
