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“The diversity of medical documentation workflows reflects the cognitive demands placed on clinicians, yet most systems do not account for these differences. ”

Medical documentation is not a one-size-fits-all process. Each care setting—from acute visits to long-term chronic care—requires distinct workflows, and understanding these is key to improving how clinicians document and review patient information. This post breaks down these workflows and explores how a medical AI scribe can streamline the process, making information easier to capture, update, and retrieve.

Chart Review vs. Documentation Generation

Effective clinical workflows depend on both chart review and documentation generation, each with unique demands.

Chart Review involves quickly accessing key information:

• Review deep, longitudinal histories of chronic conditions.

• Access recent updates to provide full clinical context for new problems.

• Quickly scan isolated issues, such as an acute visit summary, with minimal effort.

Documentation Generation involves:

• New problem entries, often structured with templates to ensure completeness.

• Micro-updates that evolve patient records over time without duplication. This allows information to appropriately persist without creating outdated or erroneous information. 

• Flexible entries like family histories, medication trials, and patient instructions, which don’t fit within standard SOAP formats but are crucial for care.

Acute Care: Efficient Notes for One-Time Problems

Acute visits, such as urgent care encounters, require concise, problem-specific documentation. A medical AI scribe can help generate these notes quickly and store them appropriately—keeping them accessible when needed but hidden otherwise, as these notes rarely need future review.

Medium-Term Care: Seeing the Full Picture

For conditions like newly diagnosed hypertension, clinicians need a holistic view of the patient’s health. A visit for depression, for instance, may also require insights into prior stress or anxiety. These workflows require flexible tools to provide broader context across multiple issues, ensuring that clinicians aren’t limited to a single, isolated problem at a time.

Long-Term Care: Tracking Chronic Issues Over Time

Chronic conditions benefit from problem-based documentation that grows with the patient and the problem. Reviewing micro-updates or accessing a condition’s longitudinal history provides clarity without the burden of re-documentation. A medical AI scribe that supports version histories and structured recaps ensures continuity of care and more efficient follow-up.

Wellness Visits: Evolving Checklists for Preventive Care

Annual physicals and well-child visits require dynamic documentation. These visits involve preventive care items that need to be updated, added, or removed over time based on relevance. A flexible documentation tool ensures clinicians can track what was discussed or addressed while keeping unnecessary information out of sight and maintaining previously discussed information that still holds true. 

Administrative Workflows: Streamlining Non-Clinical Tasks

Forms, authorizations, and referrals add an administrative burden to care. Tools that streamline these workflows—integrating administrative documents with clinical notes—help ensure seamless care transitions and reduce clinician workload.

The Pitfall of Copy-Paste: Breaking the “Source of Truth”

Copy-pasting information is a workaround clinicians use to maintain access to essential data without constantly hunting for it. However, this practice creates duplication, errors, and outdated information by breaking the link to the original source of truth. Instead, clinicians need tools that allow for persistent, linked information that remains accessible without requiring re-documentation.

Rethinking Documentation to Support Clinicians

The diversity of medical documentation workflows reflects the cognitive demands placed on clinicians, yet most systems do not account for these differences. A well-designed medical AI scribe adapts to various workflows, ensuring that both chart review and documentation generation are aligned with clinical needs. Whether the task is managing an acute visit, tracking chronic conditions, or organizing wellness checkups, an adaptable system allows information to persist, evolve, and remain accessible without unnecessary duplication.

By understanding the ontology of medical workflows, we can design tools that match how clinicians think and work—enabling better care and more efficient documentation.