Clinical Documentation Companies: United States

What is clinical documentation?

Clinical documentation refers to any notes—whether on paper or electronic—that a clinician records regarding a patient’s condition or treatment within their medical record. It encompasses both digital and analog records related to medical procedures, clinical trials, or tests. High-quality clinical documentation is vital for establishing accurate medical statistics.

It is essential for clinical records to be accurate, up-to-date, and reflective of the specific services provided to a patient. Such records often include supporting electronic files, including MRI images, X-rays, electrocardiograms (EKGs), and monitoring recordings, alongside the main documentation.

Clinical documentation providers:

• Suki:

Suki offers AI-powered, voice-enabled clinical documentation solutions. This technology provides clinicians with a computer assistant capable of listening to patient-doctor interactions, recording them, and helping physicians take verbal notes in natural language. It leverages cloud computing and natural language processing (NLP).

• Simbo.AI:

Simbo.AI acts as a “virtual resident physician” that aids doctors in creating clinical documentation. This AI performs real-time documentation based on conversations between doctors and patients, along with commands from the physician, enabling them to stay focused on patient care instead of administrative duties. Simbo’s AI-powered medical scribe technology not only simplifies note-taking but also summarizes doctor-patient discussions, ensuring accurate documentation in EHRs without disrupting current workflows.

• Nuance:

In many ambulatory settings, about 30% of patients see their physicians for less than ten minutes. Nuance provides a clinical documentation service that automates writing, allowing physicians to use their time more efficiently and cut documentation time by over 50%. By using voice navigation, dictation, and editing tools within the EHR, clinical staff can allocate more time to patients.

• DeepScribe:

DeepScribe is dedicated to ensuring that technology serves the healthcare profession rather than the other way around. By leveraging their expertise in AI and machine learning, they have crafted a robust documentation solution intended to enhance the patient-provider relationship, allowing professionals to prioritize patient treatment over documentation tasks.

•  Augmedix:

Augmedix focuses on rehumanizing healthcare by enabling physicians to offer the best possible patient care. Their Clinical Documentation Specialists are central to this mission, acting as professional aides to assist physicians in delivering exceptional patient care. Augmedix employs innovative technology, allowing anyone, anywhere in the world to scribe at any time.

• Augnito:

Augnito offers a solution with 99% accuracy right out of the box, providing rapid and effortless methods for capturing real-time clinical data from any device, anywhere. Augnito enables a fourfold increase in productivity for patient data entry compared to traditional typing and can save clinicians at least three hours of documentation time each day. Their templates, macros, and custom terminology can be used from any workstation, whether at the office, home, or on the go.

• Robin:

Robin is creating a more direct care approach by combining advanced technology with human expertise, enabling physicians to regain control over their practice and their time. The unique Robin Assistant device passively monitors conversations between doctors and patients to capture the necessary details for crafting medical notes and codes. By streamlining workflows, Robin decreases wait times in clinics and delivers exceptional accuracy in documentation for physicians.

• Freed:

Freed Associates leads a clinical documentation improvement program that has helped a medical center enhance its publicly reported quality scores through better physician documentation guidelines in an EHR system. Freed facilitates a smoother transition for providers adapting to ICD-10, especially when increased specificity in documentation is required.

• Ambience:

Ambience’s flagship product, Ambience AutoScribe, is an entirely automated AI medical scribe that seamlessly integrates into EMR workflows, capturing the nuances of provider-patient communication in real time to create detailed records. Adopted by provider groups across North America, Ambience dramatically reduces documentation time by 76%, allowing caregivers to focus on what truly matters.

• Chartnote:

Chartnote is designed as a productivity tool to help restore the joy of practicing medicine. Its templates and speech recognition capabilities simplify medical documentation, freeing up more time for patient care. Chartnote enables doctors to rapidly and easily produce accurate and consistent documentation, allowing them to dictate notes and charts that are then transcribed into text, thereby saving time and minimizing errors.

How to choose the best clinical documentation software?

Clinical documentation improvement (CDI) aims to enhance the accuracy of EHR data for various applications, including quality reporting and patient care.

This software can be used for patient notes in various healthcare settings, including hospitals, clinics, and private practices. It is particularly beneficial for health practitioners who work long hours and need quick, efficient methods to record patient encounters without spending excessive time on paperwork.

•  HIPAA Compliance:

Reputable medical dictation software will demonstrate independent verification of its compliance with PHI (Protected Health Information) and HIPAA (Health Insurance Portability and Accountability) regulations. It’s advisable to request evidence of an independent audit from the software developer, especially when their multilingual dictation application collects electronic PHI.

• Accessibility:

Ease of use is undoubtedly a critical factor in an EMR system. Most medical practitioners prefer dictation software that is user-friendly across various platforms and applications.

• Security:

Mobile dictation has become feasible through tablets or smartphones, and data security is enhanced through sophisticated network protections.