How AI Scribe Transforms Your Clinical Workflow

If you are seeing the patient based on an Appointment, you simply select the Log Consultation option on the appointment or just use the Add Consultation option. It is useful to quickly review a summary of the patient’s health profile from the patient health record before starting the encounter.

During the Patient Encounter

Once you start the AI Scribe recording, you can conduct your patient encounter exactly as you normally would. Speak naturally with your patient, conduct your examination, and explain diagnoses and treatment plans— all without worrying about taking notes or entering data into forms. Alternatively you can also choose to dictate an overview of the encounter.

The AI system captures not just the words spoken, but the clinical context. It identifies when you're gathering history versus conducting an examination versus explaining a treatment plan. It recognizes medical terminology, drug names, dosages, and clinical reasoning. Importantly, it distinguishes between conversation directed at the patient versus clinical observations you might voice for documentation purposes.

The system is designed to be unobtrusive. There's no need to speak differently, pause for dictation, or follow specific verbal formatting. You maintain natural conversation flow while the AI handles the complex task of extracting and organizing clinically relevant information.

Automatically Drafting the Consultation Document

After completing the patient encounter, you can use the AI Scribe to draft a structured, professionally formatted clinical document, by choosing the document template you need e.g. SOAP Note or Patient Visit Summary etc. The AI Scribe will draft an organized clinical note that follows proper medical documentation standards and includes all the essential elements for your chosen document type.

The AI Scribe generated document organizes information logically from multiple sources: information from the encounter transcript and any notes that you might have manually added during the consultation. It also incorporates relevant context from the patient's existing health record, including current health conditions and medications, known allergies, social history and family medical history. This contextual awareness ensures that generated documents maintain clinical continuity and reference pertinent medical history, creating more comprehensive and clinically relevant documentation.

It is important to note that you can create more than Consultation Document for a patient consultation, for example you can create SOAP Note for your records and also a Patient Visit Summary for the patient. For patients requiring referral to another healthcare provider you can create a Referral Letter or choose to issue a Medical Certificate for a patient needing that for their place of work or study.

Provider Finalizes the Consultation Document with AI Scribe Support

Once AI Scribe generates the initial document, providers must carefully review and edit the content to ensure clinical accuracy and completeness. This review process can be conducted through traditional manual editing or by providing AI Scribe with specific instructions for modifications, such as adding clinical insights, refining diagnoses, or restructuring sections. The provider retains full control and responsibility for the final document content and clinical decisions.

Clinical Decision Support Integration

The AI Scribe feature securely leverages advanced AI language models that understand medical terminology, clinical reasoning patterns, and the different phases of patient encounters. Through expertly designed clinical templates and prompts, the system organizes clinical conversations into structured documentation that meets specialty-specific requirements, whether for primary care, mental health, surgical consultations, or other medical specialties. This AI foundation enables accurate recognition of medical concepts while the clinical templates ensure information is organized appropriately for professional healthcare documentation.

Custom Template Creation: Tailoring Documentation to Your Practice

While AI Scribe includes standard templates for SOAP Notes, H&P Notes, Patient Visit Summaries, Referral Letters, and Medical Certificates, providers can create custom templates using the AI Scribe assistant.

Templates can be of different types

Assessment and Planning Assistance

While AI Scribe never replaces clinical judgment, it can provide helpful organizational structure for clinical reasoning and treatment planning. Based on documented symptoms, examination findings, and clinical context, the system can suggest relevant diagnostic considerations or treatment approaches for your review.

These suggestions are based on established clinical guidelines and evidence-based medicine principles, but they always remain suggestions for your clinical consideration rather than definitive recommendations. Your medical expertise and clinical judgment remain paramount in all diagnostic and treatment decisions.

Differential Diagnosis Organization

When you mention multiple diagnostic possibilities during your clinical reasoning, AI Scribe can help organize these considerations systematically. It can structure differential diagnoses logically, ensure that ruling-out processes are documented appropriately, and help organize the clinical reasoning that supports your final diagnostic conclusions.

Treatment Planning Structure

Complex treatment plans involving multiple interventions, medications, lifestyle modifications, and follow-up arrangements can be organized systematically by AI Scribe. The system ensures that all treatment components are clearly documented. The provider needs to ensure that the prescribed medication and dosages are accurate, and follow-up instructions are comprehensive and clear.

• Notes
• Care Plans
• Letters
• Certificates

They can also be mapped to a relevant Specialization.

Custom templates serve three key purposes:

• Specialty-specific needs (e.g. paediatric templates emphasizing developmental milestones, geriatric templates focusing on functional assessments)
• Practice integration (incorporating your specific terminology, documentation conventions, or patient population requirements)
• Compliance alignment (meeting organizational guidelines, specialty board requirements, or institutional documentation standards)

The template builder allows you to define custom sections, specify required information fields, and establish documentation workflows that align perfectly with your clinical practice.

Template Library & Team Templates

Each provider maintains their own Template Library, while organizations can create Team Templates available to all providers in the Virtual Practice. Providers can also share their personal templates as Team Templates for colleagues to use.

Seamless EHR Integration

AI Scribe is designed to integrate smoothly with existing electronic medical record systems. Generated documents can be directly transferred to the patient’s charts, depending on the visibility setting on the document. Patients can receive notifications when relevant documentation is available in their record, so that they can log into their own user account in the Virtual Practice and securely view it.

Practice Management Compatibility

The system works with various practice management workflows, whether you see patients in traditional office settings, hospital environments, or telehealth consultations. Documentation can be generated in real-time during in-person encounters or compiled after telehealth consultations based on your preferred workflow.

Quality Improvement Support

AI Scribe documentation can support quality improvement initiatives by ensuring consistent documentation standards.

Security, Privacy, and Compliance

HIPAA Compliance and Data Protection

Patient privacy and data security are fundamental to the Virtual Practice’s design and operation and this applies to the AI Scribe feature too. All patient information is processed using HIPAA-compliant systems with end-to-end encryption, secure data transmission, and strict access controls.

The system employs industry-standard security measures including data encryption at rest and in transit, multi-factor authentication, regular security audits, and comprehensive access logging. Patient data is processed only as necessary for documentation generation and is never used for other purposes.

Data Retention and Deletion

AI Scribe follows strict data retention policies that minimize patient data storage duration. Audio recordings and transcripts are deleted according to predetermined schedules that balance clinical needs with privacy protection. The system maintains detailed audit logs of all data handling activities while protecting patient confidentiality.

Measuring the Impact on Your Practice

Regulatory Compliance

The system is designed to meet various regulatory requirements including HIPAA and GDPR. Providers are required to confirm patient consent before any audio transcribing.

Professional Liability Considerations

AI Scribe is designed as a documentation assistance tool that supports but never replaces physician clinical judgment and responsibility. All generated documents require physician review and approval, ensuring that medical liability and professional responsibility remain clearly with the treating physician.

Measuring the Impact on Your Practice

Time Savings and Efficiency Gains

Most providers experience significant documentation time savings with AI Scribe implementation. While specific time savings vary based on documentation complexity and individual practice patterns, many providers report 50-70% reduction in time spent on clinical documentation.

This time savings translates into multiple benefits: more time available for patient care, reduced need for documentation during personal time, decreased administrative burden, and improved work-life balance. Some providers use the saved time to see additional patients, while others invest it in more comprehensive patient interactions or professional development activities.

Documentation Quality Improvement

AI Scribe often improves documentation consistency and comprehensiveness. The system ensures that important clinical elements are consistently included in documentation, reduces the likelihood of missing critical information, and maintains professional documentation standards even when providers are rushed or fatigued.

Improved documentation quality supports better patient care through enhanced communication between providers, more comprehensive clinical records for future reference, and better support for quality improvement and clinical research activities.

Patient Interaction Enhancement

Perhaps most importantly, AI Scribe allows providers to maintain full attention on patients during clinical encounters. Without the distraction of note-taking or data entry, providers report more meaningful patient interactions, better patient satisfaction, and improved clinical relationships.

Patients often appreciate having their provider's full attention during consultations and report feeling more heard and understood when providers aren't divided between patient interaction and documentation requirements.

The Future of Clinical Documentation

Evolving Capabilities

AI Scribe represents the beginning of a transformation in clinical documentation that will continue evolving with advances in artificial intelligence, natural language processing, and clinical informatics. Future developments may include even more sophisticated clinical reasoning support, enhanced integration with diagnostic tools and clinical decision support systems, and expanded capabilities for complex clinical scenarios.

Supporting Value-Based Care

As healthcare continues shifting toward value-based care models that emphasize patient outcomes and care quality, comprehensive and accurate documentation becomes increasingly important. AI Scribe supports this transition by ensuring that clinical care is thoroughly documented, and care coordination is effectively supported through clear clinical communication.

Professional Development and Education

AI Scribe can support medical education and professional development by providing excellent examples of clinical documentation, supporting teaching activities through clear clinical records, and helping healthcare providers learn and maintain high documentation standards throughout their careers.