ProductClinical Documentation Assistant
Documentation
Structured notes from the way clinicians already write.
The Clinical Documentation Assistant turns free text and dictation into complete, structured notes in the format your hospital uses, and points out anything that needs a second look.
Typed by the midwife
34 yrs G2P1 28/40. Feels well, no headache, no visual symptoms. BP 142/94. Urine protein +. Fundal height 28 cm. FHR 144.
Structured note
- History
- Gravida 2, para 1, 28 weeks. No headache or visual symptoms.
- Exam
- BP 142/94Urine protein 1+SFH 28 cmFHR 144/min
Flag for the clinician
Raised blood pressure with proteinuria after 20 weeks. Assess for pre-eclampsia per protocol.
What it does
Complete notes, in your hospital's format.
- SOAP and clinic notesFree text becomes a structured note with history, examination, assessment and plan.
- Antenatal visitsGestation, blood pressure, urinalysis, fundal height and fetal heart rate captured in the antenatal record.
- Procedure notesIndication, procedure, findings and post-procedure plan in a consistent layout.
- Referral lettersA clear referral letter drafted from the encounter, ready to print or send.
Watch
Clinical Documentation Assistant in 30 seconds.
Safeguards
The clinician stays in charge.
Used in outpatient clinics, antenatal clinics, wards and theatres.
- Drafts are marked as draftsNothing is filed until the clinician reviews and signs it.
- The clinician's words are keptThe assistant structures and completes notes. It does not change clinical findings.
- Gaps are flaggedMissing vital signs, allergies or plans are highlighted before signing.
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