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Auscultation Notes Doctor-patient dialogue medical record generation workbenchMedical AI document automation / Environmental voice medical record generation · V74
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Medical AI document automation / Environmental voice medical record generation

Convert diagnostic and treatment environment conversations into standardized medical record drafts that are verifiable and reviewable

Generate a standardized medical record draft with original fragment evidence citations from the audio or transcribed content of doctor-patient conversations, and allow doctors to review, edit and quality-control paragraph by paragraph before confirmation.

  1. 01
    Consent and collectionRecord patient consent status, upload diagnosis and treatment audio or enter transcribed text.
  2. 02
    Transcription and terminology trackingGenerate speaker segmented transcriptions and extract traceable medical terms.
  3. 03
    Medical record draft generationGenerate standardized medical record drafts based on templates with evidence citations.
  4. 04
    Doctor review and confirmationPhysicians review, edit, return or confirm draft medical records section by section.
  5. 05
    Export and auditExport reports and audit records of this site and do not write them to external systems by default.
Draft medical record pending review0 drafts pending reviewCount the number of clinical_note_draft.status in the current project that is draft or needs_review.
Terms to checkNo need to check terminology yetCount the number of terms for which medical_term_trace.needs_review is true or where confidence is lower than 0.75.
Medical record evidence coverageNo draft medical record has been generated yetThe number of medical record paragraphs with evidence_links / the total number of key paragraphs in medical records.
Pending attachmentsNo attachments to be processed yetCounts the number of attachments for which attachment_parse_record.parse_status is not parsed or approved_for_note is not true.
BUSINESS INPUT

New project

A diagnosis and treatment record item corresponds to a closed loop of a doctor's processing of a doctor-patient conversation: recording / transcription, term recognition, medical record draft, doctor review and export.

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TRACEABLE OUTPUT

Draft medical record

Results, sources, failures, approvals, and rollbacks are saved by project.

0 live runs

No business results yet

Transcription has not been generated yet. Please upload the approved diagnosis and treatment audio.

PRIVACY

Data use boundary

This product handles diagnosis and treatment audio, doctor-patient conversations, anonymous patient identification, doctor identification, medical terminology, and attachments that may contain health information. Please obtain explicit patient consent for recording, transcription, and draft medical record generation before uploading, and use anonymous patient numbers whenever possible. These records may not be viewed, exported or shared by unauthorized personnel. Current 10 Role Review Supplement: Minimal Collection: Attachments, full audio, and full transcriptions are only processed as necessary to complete core tasks; attachments must not be required for term identification. ;Access Control: Grant access by role to audio, transcriptions, patient references, attachments, medical record drafts, review notes, and export packages, and log audit events. ;Deletion verification: Deletion of original audio, attachments, exported files and complete text must have queryable status, failed retry and desensitization audit summary. ; Log desensitization: Ordinary logs must not contain complete audio, complete transcription, complete medical record text, direct patient identity information or unauthorized attachments. ;Retention policy: The 30-day default retention is a product design, not a video evidence; institutional configuration, production PHI applicability, encryption and compliance responsibilities are all unknown before the code / is not provided.

RETENTION

Data retention

By default, project data on this site is retained for 30 days; organization administrators can shorten the retention period. When a user deletes an item, the site's audio, transcription, terminology, drafts, attachments, and review records enter the deletion queue; the audit summary can be retained according to compliance requirements, but it should not include the complete audio or the complete text of the medical record.

SAFETY

Human responsibility and rollback

The content generated by this product is only a draft of medical documents and quality control auxiliary information, and cannot replace a doctor's diagnosis, treatment decision-making, medical record signing, or the formal archiving process of a medical institution. All medical record content must be reviewed, revised and confirmed item by item by a qualified clinician before it can be used in medical records.

Rollback only means canceling the medical record draft version, review status, export package or workflow stage generated in this site, and restoring to the previous record on the site; since this product does not connect to external production EHR or formal medical record systems by default, rollback does not mean canceling records in any external production system.