Structure a recap
Turn dictated or typed encounter details into SOAP, DAP, BIRP, or a practice-defined format.
AI clinical notes
A first draft can be automatic. The clinical record cannot be.
Use AI to organize the information you provide, then review the facts, reasoning, plan, privacy, and required documentation before the note enters the chart.
Explore the workspaceWhat the term means
AI clinical notes are generated drafts built from clinical source material.
The source may be a clinician's dictation, typed recap, transcript, uploaded document, or structured data supplied by an approved system. A language model then organizes that material into a requested note format or helps refine an existing draft.
The quality of the note depends on the quality and completeness of the source, the instructions, the model's behavior, and the clinician's review. Fluency is not evidence that every fact is present or correct.
Good uses
Give the system language work, not clinical authority.
Condense a source
Summarize a referral, prior note, or uploaded document while keeping the original available for verification.
Improve clarity
Reorganize a draft, remove repetition, and make assessment and plan easier to distinguish.
Standardize a team
Use shared instructions and templates so recurring documents begin with the same required structure.
The boundary
What an AI note system should not decide.
Whether a diagnosis is supported.
Which risk level applies to a patient.
Which medication or dose should change.
Whether an omitted fact is clinically irrelevant.
Whether a service meets a payer's requirements.
Whether the final note is ready to sign.
Seven-point review
Read the note like the next clinician will.
Review is not a quick scan for grammar. It is a comparison between the generated draft, the encounter, and the source record.
- 01Confirm the patient and encounter context.
- 02Check symptoms, findings, medications, dates, doses, and measurements against the source.
- 03Remove details that were not provided or observed.
- 04Make uncertainty visible instead of accepting confident wording.
- 05Verify that assessment and plan reflect the clinician's actual judgment.
- 06Check specialty, payer, organizational, and jurisdictional requirements.
- 07Sign only after the draft says what the clinician intends to place in the record.
PHI and the drafting path
A correct note can still come from an unapproved data flow.
Before using patient information, verify the exact account, BAA, feature coverage, data journey, retention, access controls, integrations, and incident process. Review audio, attachments, logs, exports, and support access—not only the chat box.
AI output quality and HIPAA safeguards are separate controls. A workflow needs both. Learn more in the clinician PHI checklistand the security brief.
Choose the format intentionally
SOAP, DAP, and BIRP ask different questions of the same encounter.
The required format may be determined by specialty, payer, organization, or EHR. When there is flexibility, choose the structure that makes the relevant facts, intervention, clinical reasoning, response, and plan easiest to follow.
Compare the three formats →