Primary care & family medicine
High-volume clinics where E&M accuracy and same-day closure drive revenue.
AI Agent · Clinical Documentation
AI Medical Scribe / Clinical Documentation
An ambient scribe that drafts a structured clinical note and proposes ICD-10/CPT codes, then writes to the chart only after the clinician signs off.
Human-in-the-loopHIPAA-ReadyAudit LoggedFHIR R4
Trusted by global innovators
Documentation is the tax on every visit
Clinicians spend one to two hours on notes per hour of care — driving rushed notes, missed detail, and burnout. This agent inverts that: ambient capture records the visit, ASR transcribes it, and an LLM structures a SOAP or specialty note with a coded assessment and ICD-10/CPT suggestions. Nothing files until the clinician signs, when it writes back to the EHR as a FHIR DocumentReference on the Encounter.
How the note reaches the chart
Ambient audio to structured note to coded, signed EHR write-back, clinician-controlled at every step.
Key Capabilities
Concrete outputs on every encounter — not generic 'AI-powered' features.
Ambient capture, no dictation
Diarized multi-speaker capture from an in-room device or telehealth stream — no dictation.
ASR + LLM note structuring
A medical-tuned model transcribes; an LLM structures a SOAP or specialty note from your templates, grounded in what was said.
ICD-10 / CPT / HCC suggestions
Coded ICD-10 diagnoses, CPT/E&M levels, and HCC candidates, each linked to its supporting transcript line.
FHIR DocumentReference write-back
On sign-off, writes back as a FHIR R4 DocumentReference on the Encounter, with the coded assessment as Condition and Procedure resources.
Who runs it
Deployment scenarios
Where an ambient scribe earns its keep across care settings.
Specialty outpatient
Cardiology, orthopedics, and others with structured notes and procedure coding.
Telehealth
Virtual visits captured from the video stream, filed before the call ends.
Behavioral health
Long narrative visits where documentation burden is heaviest.
Urgent care
Fast-turnover settings needing rapid, coded documentation.
HCC / risk-adjusted panels
Value-based practices needing consistent HCC capture.
Where the time goes back
Expected-impact framing, validated per practice during pilot, not guaranteed numbers.
Hours/day
Documentation time targeted for clinician recovery
Every note
Coded with ICD-10/CPT suggestions before sign-off
100%
Notes filed only after clinician signature
Compliance-First Healthcare App Development Services Backed by Global Standards
15-Minute Scoping Call01
HIPAA
Health Insurance Portability and Accountability Act
Protect PHI with privacy-first architecture, encrypted storage and transmission, strict access controls, and traceable audit logs.
02
GDPR
General Data Protection Regulation
Implement lawful consent flows, data minimization, retention controls, and secure processing for sensitive health data.
03
FHIR
Fast Healthcare Interoperability Resources
Enable standardized health data exchange across apps, care teams, and systems through robust FHIR-ready APIs.
04
HL7
Health Level Seven International
Support enterprise-grade interoperability with HL7-based integrations for records, events, and clinical messaging workflows.
05
HITRUST
Health Information Trust Alliance
Align security programs to healthcare-specific control and risk management practices trusted by providers and ecosystem partners.
06
HITECH
Health Information Technology for Economic and Clinical Health Act
Design with breach notification readiness, digital record safeguards, and operational controls that support regulated care programs.
07
SaMD
FDA Software as a Medical Device
Plan software quality, traceability, and documentation pathways for products that may require SaMD review and submission.
08
MDR (EU)
Medical Device Regulation (European Union)
Prepare EU market-ready processes for risk classification, evidence tracking, and lifecycle governance under MDR expectations.
09
SAMHSA
Substance Abuse and Mental Health Services Administration
Apply confidentiality controls and consent-aware sharing models for behavioral and mental health data experiences.
Standards we build against
Compliance & interoperability standards
HIPAASOC 2FHIRHL7ICD-10CPT
How It Works
From spoken visit to signed, coded note
Capture, structure under guardrails, review, and write back only what the clinician signs.
1.
1 · Capture
Ambient audio is captured and diarized in a BAA-covered environment; raw audio is discarded after transcription.
PHI in BAA scope
2.
2 · Process (model + guardrails)
ASR transcribes; an LLM structures the coded note (ICD-10/CPT/HCC), grounding every line in a transcript span.
Grounded, explainable
3.
3 · Clinician review
The clinician reviews the draft and each coded suggestion, edits inline, and signs; edits tune future drafts.
Human-in-the-loop
4.
4 · EHR write-back
The signed note writes to the EHR as a FHIR DocumentReference on the Encounter; diagnoses and procedures post, audit-logged.
Audit logged
Related proof
Read Case StudyLera Health: compliant women's health platform
Lera Health shows how we build the privacy-first data layer and AI-assisted workflows this agent depends on — related proof, not this exact scribe.
Compliance & Guardrails
Built for the clinical record, not a demo
Documentation touches the legal record and billing. The guardrails are the product.
PHI handling
BAA-covered infrastructure, encrypted throughout; raw audio never trains shared models.
Human-in-the-loop
The clinician signs every note and accepts every code; the agent never files autonomously.
Explainability
Each sentence and code links to its transcript span, so reviewers verify rather than trust.
Audit logging
Every action is logged with user, timestamp, and version — a defensible trail for appeals.
Frequently Asked Questions
Yes. Everything runs in BAA-covered infrastructure with encryption, role-based access, and audit logging, and raw audio never trains shared models. We sign a BAA before any PHI is processed.
Ready to take documentation off the clinician's plate?
Tell us your EHR and specialties; we'll return a pilot plan with the FHIR write-back, coding scope, and sign-off workflow mapped out.
contact@agnotic.com
Partnerships
contact@agnotic.com