Clinical Documentation Assistance
Less time typing, with clinicians in charge.
AIS can help clinicians with draft summaries and structured notes from information already recorded, for the clinician to review, correct and sign.
Clinical documentation assistance is offered subject to clinical validation and governance by your organization. Drafts are never final until a clinician reviews and signs them.
A draft is never final until a clinician reviews and signs it.
The challenge
Why it matters
Clinicians spend a large part of their day writing notes, summaries and letters, often after their shifts.
Documentation support can help, but only if clinicians stay fully in control of what is recorded, and it is introduced under your clinical governance.
What it does
What Clinical Documentation Assistance can help with
Draft summaries
Draft discharge and handover summaries from information already in the record.
Structured note assistance
Organise notes into your templates, for the clinician to complete.
Clinician review and sign-off
Every draft is reviewed, corrected and signed by a clinician.
Governance
Introduced with clinical validation, audit trails and your governance process.
How it works
Clinical Documentation Assistance, step by step
- GatherInformation already recorded for the patient.
- DraftA draft in your template, clearly marked as a draft.
- Human reviewReviewThe clinician reads, corrects and completes it.
- Human reviewSign offThe clinician signs; only then is it final.
- RecordSaved to the record, with an audit trail.
Integrations
Connected to the systems you run
AIS integrates with what you already use rather than adding another system to maintain.
- Electronic health record (EHR)
- Hospital information system (HIS)
- Clinical templates
- Audit logging
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