The Assessment & Plan (A/P) section is the most cognitively demanding part of clinical documentation. It requires synthesizing data, outlining treatment strategies, and communicating clinical reasoning—while meeting payer, compliance, and quality requirements. For many clinicians, writing A/P notes is what extends charting late into the evening.
AI-powered pre-charting changes this by drafting assessments and plans automatically, modeled after each provider’s voice and informed by clinical best practices. Providers remain fully in control—the AI simply gives them a high-quality starting point that mirrors how they already document.
AI Begins by Learning Each Provider’s Clinical Voice
Every clinician writes differently:
- Some use long narrative paragraphs
- Some prefer concise bullet points
- Some list multiple differentials
- Others jump straight to the plan
- Some emphasize patient education
- Others emphasize medication reasoning
AI analyzes historical notes to understand:
- Tone
- Structure
- Level of detail
- Common phrasing
- Condition-specific approaches
- How plans are typically articulated
The result is a personalized model of how that provider thinks and documents.
AI Builds the Assessment Using Clinically Relevant Inputs
To generate accurate assessments, AI analyzes:
- Active diagnoses
- Visit type and chief concern
- Recent labs, imaging, and vitals
- Specialist recommendations
- Medication changes
- Chronic condition patterns
- Social or behavioral risk factors
- Relevant quality measures
It then synthesizes this into a clear, structured assessment that reflects the clinical situation—not a boilerplate template.
Example (diabetes follow-up):
- A1C trends upward from 7.2 → 8.1 over 6 months
- Patient missed 2 medication fills
- No recent microalbuminuria test
- Foot exam overdue
AI integrates these findings into a clinically meaningful narrative.
AI Drafts the Plan Using Provider Habits + Clinical Guidelines
AI blends two key inputs:
1. The provider’s historical plan patterns:
- Preferred medications
- Typical lifestyle recommendations
- Thresholds for ordering labs or imaging
- Follow-up timing
- Diagnostic sequences
2. Current clinical guidelines and safety rules
- Evidence-based standards
- Drug interaction considerations
- Contraindications
- Quality measure requirements
This combination ensures the plan is both personalized and clinically sound.
AI Adapts Plans Condition by Condition
Each diagnosis receives its own tailored plan:
- Chronic disease management
- Acute issues
- Medication adjustments
- Preventive care
- Follow-up recommendations
- Referrals and coordination
- Diagnostic orders
Instead of a generic note, the plan reads like something the provider wrote themselves—but faster.
AI Automatically Includes Relevant Care Gaps
The system identifies whether the patient is missing:
- Annual screenings
- Vaccinations
- Chronic condition monitoring
- Behavioral assessments
- Recommended labs
These are woven into the plan naturally, ensuring quality compliance without the provider having to remember each requirement.
AI Flags Safety Issues Within the Plan
Before the provider reviews it, AI scans the generated plan for:
- Medication conflicts
- Dosing inconsistencies
- Redundant therapies
- Missing monitoring tests
- Payer requirements for certain orders
This improves safety and minimizes downstream corrections.
Providers Stay Fully in Control
AI-generated A/P notes are drafts—not final documentation.
Providers:
- Edit
- Approve
- Add nuance
- Remove unnecessary details
- Adjust based on patient conversation
The goal is to reduce total writing time while preserving clinical judgment.
Many clinicians report that AI drafts reduce documentation time by 50–70% without compromising quality.
The Impact: Faster Notes, Clearer Reasoning, Better Care
Automated A/P drafting leads to:
- More consistent, complete documentation
- Stronger clinical reasoning documentation for payers
- Reduced cognitive load
- Less after-hours charting
- Clear, actionable plans for care teams
- Improved coding accuracy
- Better productivity and less burnout
AI doesn’t replace the provider’s expertise—it amplifies it, ensuring each note reflects high-quality clinical thinking with a fraction of the effort.
