AI-Assisted Clinical Documentation
Deploy ambient AI to automate clinical note-taking, reducing physician documentation burden by 60% while improving note quality and completeness.
Transformation
Before & After AI
What this workflow looks like before and after transformation
Before
Physicians spend 2-3 hours daily on documentation — typing clinical notes, coding diagnoses, and completing forms. This "pajama time" documentation contributes to burnout, reduces patient face time, and leads to incomplete or delayed records. Coding accuracy averages 82%, causing revenue leakage from undercoding.
After
Ambient AI listens to patient encounters and generates structured clinical notes in real-time. Physicians review and approve notes in 2-3 minutes instead of writing from scratch. Documentation happens during the encounter rather than after hours. Coding accuracy improves to 95%+ with AI-suggested codes.
Implementation
Step-by-Step Guide
Follow these steps to implement this AI workflow
Select & Configure AI Platform
2 weeksEvaluate ambient documentation solutions (e.g., Nuance DAX, Abridge, Suki) for your clinical setting. Key criteria: specialty coverage, EHR integration, language support, and data privacy compliance. Configure for your documentation templates and clinical workflows.
Pilot With Champion Physicians
4 weeksStart with 3-5 physician champions across different specialties. Install ambient recording devices in exam rooms. Train physicians on interacting naturally with AI documentation. Collect feedback on note quality and workflow impact.
Refine & Expand
4 weeksIterate on AI configuration based on pilot feedback. Customise templates for specialty-specific documentation requirements. Build physician training materials based on lessons learned. Expand to additional departments.
Integrate With Revenue Cycle
3 weeksConnect AI-generated notes with coding and billing workflows. Implement AI-suggested diagnosis codes (ICD-10) and procedure codes (CPT). Train coders to validate AI suggestions rather than code from scratch.
Scale & Measure
2 weeks + ongoingRoll out to all clinical departments. Track key metrics: documentation time, note completeness, coding accuracy, physician satisfaction, and revenue capture improvement. Report outcomes to clinical leadership.
Tools Required
Expected Outcomes
Reduce physician documentation time by 50-60%
Improve coding accuracy from 82% to 95%+
Increase patient face time by 30-40%
Capture 5-10% additional revenue from reduced undercoding
Improve physician satisfaction scores related to administrative burden
Solutions
Related Pertama Partners Solutions
Services that can help you implement this workflow
Frequently Asked Questions
Leading ambient AI platforms are HIPAA-compliant and process data with enterprise-grade encryption. Audio is typically processed in real-time and not stored permanently. Patient consent workflows should be built into your process — patients must be informed that AI is assisting with documentation. Data handling policies should be reviewed by your compliance team.
Primary care and internal medicine see the biggest time savings because of high documentation volumes. Specialties with structured encounter formats (orthopaedics, dermatology, ophthalmology) achieve high accuracy quickly. Complex specialties (oncology, psychiatry) may need more customisation but still see significant benefits.
Ready to Implement This Workflow?
Our team can help you go from guide to production — with hands-on implementation support.