What you need
Data sources
- EHR system — patient encounters, diagnoses, orders, lab results, vital signs, medications, and problem lists
- Billing database — historical claim codes, reimbursement outcomes, and denial reasons
Knowledge spaces
- Clinical practice guidelines — upload condition-specific guidelines (e.g., AHA for cardiovascular, ADA for diabetes) that inform documentation standards
- Documentation templates — upload your organization’s note templates for progress notes, H&P, discharge summaries, and referral letters
| Component | Name | Definition |
|---|---|---|
| Object | Encounter | Maps to the encounters table in the EHR. Represents a single patient visit with diagnoses, orders, and notes |
| Object | Patient | Maps to patients in the EHR. Represents a patient with their complete medical record |
| Metric | Documentation Completion Rate | Percentage of encounters with finalized notes within 24 hours of the visit |
| Metric | Average Note Turnaround | Mean elapsed hours from encounter close to note finalization |
| Dimension | Visit Type | Categorizes encounters as office visit, inpatient, emergency, telehealth, or procedure |
| Dimension | Specialty | Groups encounters by clinical specialty (cardiology, orthopedics, primary care, etc.) |
Agent setup
Create the agent
Go to Agent Space → New agent.
| Field | Value |
|---|---|
| Name | Clinical Documentation Assistant |
| Role | Medical Documentation Specialist |
| Goal | Draft clinical notes from EHR encounter data and clinical guidelines, structured according to organizational templates, for physician review and finalization |
Set the description
You are a clinical documentation specialist who drafts medical notes from structured EHR data. You follow organizational note templates and reference clinical practice guidelines to ensure completeness and accuracy. You use precise medical terminology, include all relevant clinical data points (vitals, labs, medications, assessments), and structure notes for downstream coding compliance. You always produce drafts — never final notes — and flag any data gaps that the clinician should address during review.
Scope data access
Grant access to:
- EHR system (encounters, diagnoses, orders, labs, vitals, medications)
- Billing database (claim codes, denial reasons)
- Clinical practice guidelines knowledge space
- Documentation templates knowledge space
- Encounter and Patient objects, Documentation Completion Rate metric
Add skills
Progress note drafting
Progress note drafting
Trigger: User asks the agent to draft a progress note for a specific encounter.
- Retrieve the encounter record from the EHR, including chief complaint, vitals, active medications, and orders.
- Pull the patient’s problem list, recent lab results, and relevant prior encounters.
- Load the appropriate note template from the documentation templates knowledge space based on visit type.
- Reference clinical practice guidelines for the primary diagnosis to ensure documentation covers guideline-recommended elements.
- Draft the note following the SOAP structure (Subjective, Objective, Assessment, Plan) using data from the encounter.
- Flag any missing data points (e.g., vitals not recorded, labs pending) that the clinician should complete.
- Return the draft note with flagged items highlighted for review.
Discharge summary generation
Discharge summary generation
Trigger: User asks the agent to draft a discharge summary.
- Retrieve the full inpatient encounter from the EHR, including admission diagnosis, procedures performed, and daily progress.
- Pull the patient’s medication reconciliation, follow-up orders, and discharge instructions.
- Load the discharge summary template from the documentation templates knowledge space.
- Compile the hospital course narrative from daily progress entries.
- Include the discharge medication list, pending lab results, and follow-up appointment details.
- Return the draft discharge summary formatted for the receiving provider.
Referral letter drafting
Referral letter drafting
Trigger: User asks the agent to draft a referral letter to a specialist.
- Retrieve the referring encounter and the reason for referral from the EHR.
- Pull the patient’s relevant medical history, current medications, and recent diagnostics.
- Load the referral letter template from the documentation templates knowledge space.
- Include pertinent positive and negative findings related to the referral reason.
- Return the draft referral letter addressed to the receiving specialist with all supporting clinical data.
Automation
Playbook: End-of-day documentation reminder
Set the trigger
Set the trigger to Schedule — Daily at 6:00 PM to catch encounters with missing documentation before the end of the business day.
Build the workflow
The workflow identifies encounters with incomplete documentation and sends reminders:
- Query all encounters from the current day that do not have a finalized note in the EHR system.
- Loop — for each incomplete encounter, pull the encounter details and the assigned provider.
- Condition — check if a draft note already exists. If not, generate a draft using the encounter data and documentation template.
- Action — save the generated draft to the EHR system’s note queue for the provider.
- Delivery — notify providers of their outstanding documentation.
Configure delivery
- Email — send each provider a list of their encounters pending documentation, with links to pre-populated drafts
- Slack — post a department-level summary to
#clinical-opsshowing the count of incomplete notes by provider
What’s next
Medical coding review
Validate medical codes against clinical documentation to reduce claim denials.
All Healthcare use cases
See the full list.