AI-Assisted Documentation

CureCompanion’s AI-assisted documentation helps providers create comprehensive progress notes by automatically analyzing visit conversations and generating structured documentation in SOAP format. This feature streamlines the documentation process while maintaining clinical accuracy.

Viewing Call Transcripts

After a visit, you can access the transcript of your conversation with the patient through the visit details page.

  1. Navigate to the visit page
  2. Click the “View call transcript” button (with document icon) located near the top of the visit details
  3. Review the transcript in the modal dialog that opens showing the conversation
  4. Note the accuracy disclaimer stating “This AI-generated transcript may contain inaccuracies”
  5. Close the dialog using the “OK” button when finished reviewing

The transcript captures conversation participants clearly labeled (e.g., “[Dr. Jonathan Burton]”) and provides a text representation of the visit conversation. The transcript is available immediately after the visit and includes an accuracy disclaimer to remind providers to verify important details.

AI-Generated Progress Note Documentation in SOAP Format

CureCompanion automatically generates structured progress notes using the Subjective, Objective, Assessment, and Plan (SOAP) format based on your visit conversation.

Accessing AI-Generated Notes

AI documentation is automatically generated for visits and appears in the Progress Note section without requiring a separate generation button. The system processes visit conversations and creates structured SOAP notes automatically.

  1. Navigate to the Progress Note section within the visit interface
  2. Review the pre-generated documentation that appears with AI formatting
  3. Look for the AI disclaimer at the top stating “Note: This documentation has been created by AI and could contain inaccuracies. Double-check before signing the visit.”
  4. Edit the content directly using the rich text editor provided

SOAP Format Structure

The AI organizes information into four main sections:

Subjective (S):

  • Patient’s chief complaint and symptoms
  • History of present illness
  • Patient-reported information
  • Review of systems responses

Objective (O):

  • Vital signs and measurements
  • Physical examination findings
  • Diagnostic test results
  • Observable clinical data

Assessment (A):

  • Clinical impressions and diagnoses
  • Differential diagnoses considerations
  • Clinical reasoning

Plan (P):

  • Treatment recommendations
  • Follow-up instructions
  • Prescribed medications
  • Referrals and next steps

Understanding AI-Generated Assessments

The AI system analyzes the conversation context to provide clinical assessments based on the information discussed during the visit.

Assessment Quality Indicators

  1. Note accuracy disclaimers – The system displays clear warnings that “This assessment has been made by AI and could contain inaccuracies”
  2. Review assessment details – AI provides structured custom assessments. Contact the CureCompanion team to set up your own custom assessment.
  3. Cross-reference with patient history – Confirm assessments consider the patient’s medical background

Reviewing and Editing AI Suggestions

Always review and customize AI-generated documentation to ensure accuracy and completeness.

Review Process

  1. Read through each SOAP section carefully
  2. Compare with your clinical observations during the visit
  3. Verify medication names and dosages are correctly transcribed
  4. Review assessment findings – The AI provides categorized assessments
  5. Ensure patient-specific details are accurately captured

Editing Functions

  • Direct text editing – Click on any section to modify content
  • Add missing information – Include details not captured by the AI
  • Remove incorrect entries – Delete inaccurate or irrelevant content
  • Reorganize sections – Move information between SOAP categories as needed
  • Format adjustments – Use rich text features for better organization

Common Areas Requiring Review

  • Medication reconciliation – Verify current medications and new prescriptions
  • Assessment accuracy – Review AI-generated clinical assessments and categories
  • Treatment plans – Ensure recommendations align with your clinical decision
  • Follow-up timing – Adjust appointment scheduling recommendations as needed

Best Practices for AI Documentation

Before the Visit

  • Review patient history to provide context for AI analysis
  • Prepare key questions that will help generate comprehensive documentation
  • Ensure clear audio quality for accurate transcription

During the Visit

  • Speak clearly and use standard medical terminology when appropriate
  • Verbally confirm key information such as medication names and dosages
  • State clinical findings explicitly to ensure they are captured in the transcript
  • Summarize assessment and plan verbally before ending the visit

After the Visit

  • Review AI-generated content immediately while the visit is fresh in your memory
  • Make necessary corrections before finalizing the documentation
  • Add any missed clinical observations that weren’t verbally discussed
  • Verify patient instructions match what was actually communicated

Quality Assurance Tips

  1. Cross-reference with standard protocols for your specialty
  2. Ensure compliance with documentation requirements and regulations
  3. Maintain clinical judgment primacy – AI assists but doesn’t replace provider decision-making
  4. Understand AI disclosure – The system automatically marks AI-generated content with disclaimers, eliminating the need for separate documentation

Efficiency Maximization

  • Use consistent medical terminology to improve AI recognition accuracy
  • Develop templates for common visit types to supplement AI generation
  • Use rich text editor features – The system provides standard formatting tools (bold, italic, underline, lists) but does not offer custom shortcuts
  • Direct editing capabilities – Make corrections and additions directly in the AI-generated text without requiring separate feedback mechanisms

Important Considerations

  • AI documentation is a tool to enhance efficiency, not replace clinical judgment
  • Always verify accuracy before signing and finalizing notes

The AI-assisted documentation feature significantly reduces documentation time while helping maintain comprehensive clinical records. Regular use and proper review practices will maximize the benefits of this technology in your clinical workflow.