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How AI Benefits The Medical Documentation Process

Sarah Lara

Jan 23, 2024
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Artificial intelligence has evolved significantly in the past few years. Today, A.I. is utilized by a wide variety of industries, including retail, banking and finance, logistics, travel, and even food technology.

Healthcare is another industry that takes advantage of A.I. technology. In fact, according to Precedence Research, artificial intelligence in healthcare currently has a compound annual growth rate of 37%.  This increasing prominence correlates to the various ways technology can be leveraged within the healthcare space.  For instance, it can analyze medical images, provide remote patient care, and help with medical research. It can even detect early stages of fatal blood diseases.

Nowadays, A.I. is also seeing widespread use in clinical documentation. But how exactly does A.I. help patient documentation? In this article, physical therapists and healthcare professionals can learn just how beneficial A.I. for medical documentation has become.

AI in Medical Documentation Ensures Medical Coding Compliance

Medical coding is an essential process in the healthcare industry. With medical coding, the patient’s diagnosis and treatment, as well as the medical services and equipment used for said treatment, is translated into code. This code, in turn, is used to bill every patient properly. But before the code can be properly applied, this treatment information is first taken from medical documentation.

According to Becker’s Hospital CFO Report, approximately 80% of hospital bills contain errors. These errors are usually traced back to the documentation itself. Often, this is because the document is difficult to read, incomplete, or inconsistent. Integrating A.I. in medical documentation software can easily help both healthcare providers and medical coders avoid this problem.

The medical coding process can be streamlined by integrating A.I. in medical documentation. This is because A.I. medical documentation can learn from coding patterns. As a result, potential errors in the clinical documentation can be flagged, and billing errors avoided. In addition to flagging errors, A.I. in medical documentation programs can also ensure that the coding process complies with current medical coding regulations.

Medical Documentation AI Turns Clinical Notes into Actionable Insights

Documenting patient encounters can go a long way in improving the care that healthcare facilities provide. As such, it’s vital that medical documentation remains as accurate as possible. By using medical documentation tools that are integrated with A.I., clinical documentation won’t just be improved. It can also detect patterns in a patient’s diagnosis, turning them into actionable insights in the process. 

As a result of the pattern detection of the A.I. in medical scribe services, gaps in the patient’s care can be filled and noted. This allows physical therapists and healthcare professionals to provide the appropriate treatments quickly. Thanks to this, patient recovery rates can increase at a faster rate.

AI in Medical Documentation Helps Generate Precise Clinical Notes

According to an article from the Advisory Board, 49.2% of physical therapists and healthcare professionals spend most of their time on medical documentation. The same article also revealed that only 27% of their time is spent on treating patients. Oftentimes, this is due to the fact that certain healthcare facilities still have physical therapists document patient visits by hand. Additionally, if the patient is assigned to a new healthcare professional, the new doctor will also have to spend time correcting any errors their predecessor left on the patient’s medical documentation.

This extreme focus on medical documentation can result in burnout for physical therapists and other healthcare professionals. Thankfully, A.I. scribe medical documentation programs can help reduce the time spent on documenting sessions. This is because AI-driven documentation tools  can generate precise clinical notes thanks to their voice recognition capabilities. They can even extract important information about the patient’s health as the session continues.

As a result, medical documentation errors that were once caused by manual documentation can be avoided. This, in turn, allows for increased efficiency and accuracy in the field of clinical documentation.

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