Medical Documentation refers to the systematic recording of a patient’s health information, medical history, treatment plans, and clinical findings. This documentation is essential for ensuring continuity of care, facilitating communication among healthcare providers, and providing a comprehensive record of a patient’s medical encounters. It includes various forms such as clinical notes, discharge summaries, laboratory reports, imaging results, and medication records. Proper medical documentation is critical for accurate diagnosis and treatment, billing and reimbursement processes, and legal protection in the event of medical disputes. It serves as a legal record of the care provided and is often required by regulatory bodies and insurers. Overall, medical documentation is a fundamental aspect of healthcare practice that supports both patient safety and quality of care.
Clinicians at Impower were previously spending 20–25% of their time on documentation, impacting patient care. Impower implemented AI technology from Eleos to automate the documentation process during therapy sessions. The…