Provider CMIOs
Health systems that want a scribe built around their specialties and EHR.
AI in Healthcare / Clinical Documentation
AI medical scribe and ambient documentation development
Clinicians spend hours after clinic finishing notes, and a generic scribe tool rarely fits a specialty's note format or the EHR. Agnotic Technologies builds custom ambient AI scribes that turn visits into structured notes, write back to your EHR and leave the clinician in control.
Ambient captureStructured notesEHR write-backClinician sign-off
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What is AI medical scribe development?
AI medical scribe development is building software that listens to a clinical visit, with consent, and drafts a structured note such as a SOAP note for the clinician to review and sign. Agnotic Technologies builds custom ambient scribes: audio capture, transcription, note generation for your specialty templates, EHR write-back and checks for accuracy and hallucinations.
Ambient clinical documentation means the scribe works in the background of a normal conversation, so the clinician talks to the patient instead of the keyboard.
What does the clinician see after the visit?
A drafted note in the specialty's format, each section linked to the part of the conversation it came from, with items to confirm highlighted and a sign button that writes the note to the EHR.
Which specialty templates and note formats do we support?
The note format is the product. We build templates with your clinicians, not a single generic layout.
SOAP and progress notes
Subjective, objective, assessment and plan sections with your section headings.
Specialty templates
Behavioral health, orthopedics, cardiology, primary care and other specialty formats.
Structured data
Problems, medications, orders and follow-ups pulled out as structured items, not just prose.
Coding suggestions
Suggested diagnosis and procedure codes for the clinician or coder to confirm, never filed automatically.
Patient summaries
A plain-language visit summary for the patient, reviewed before it is sent.
Languages
Visits in more than one language, with the note produced in the language your records use.
SOAP note automation
How does an AI scribe draft each part of a SOAP note?
An AI scribe drafts each part of a SOAP note from a different source: the patient's words for Subjective, exam findings for Objective, the clinician's reasoning for Assessment and agreed orders for Plan. Agnotic Technologies builds it so the clinician confirms each section before signing.
Subjective
Comes from the patient's own words: symptoms, history and concerns. The scribe drafts the chief complaint, history of present illness and review of systems. The clinician confirms timing, severity and negatives, because a missed 'no' changes the meaning.
Objective
Comes from exam findings the clinician says aloud, plus vitals and device readings already in the chart. The scribe drafts the exam and data sections. The clinician confirms every finding, since anything examined but not spoken is missing from the transcript.
Assessment
Comes from the clinician's reasoning, said to the patient or dictated after the visit. The scribe drafts the diagnoses discussed and suggested codes. The clinician confirms the final diagnoses and codes; the scribe never adds a diagnosis no one stated.
Plan
Comes from the orders, prescriptions, referrals and follow-up agreed in the visit. The scribe drafts the plan and lists the orders discussed. The clinician confirms doses and follow-up, and places the orders in the EHR as usual.
Who it is for
Who builds AI scribes with us?
Most of our clinical documentation work is for one of these teams.
Digital health founders
Products where documentation is part of the care model.
Specialty groups
Practices whose note formats generic scribes handle poorly.
Telehealth platforms
Virtual care products adding notes from video visits.
Reference architecture
What does an AI scribe architecture look like?
The layout we start from and adjust to your EHR and AI providers.
Capture
- Consent record
- Mobile or room audio
- Encrypted upload
Speech
- Transcription under a BAA
- Speaker labels
- Temporary audio storage
Note generation
- Specialty templates
- Source linking
- Hallucination checks
Clinician review
- Edit and sign
- Items to confirm
- Edit tracking
EHR
- FHIR or vendor write-back
- Epic, Oracle Health and others
- Audit log
Compliance-First Healthcare App Development Services Backed by Global Standards
01
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 standards-based FHIR 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.
Compliance and security
What compliance and security requirements apply to an AI scribe?
Each requirement is an engineering decision. Agnotic claims no certification; we build so your product can pass your reviews.
| Requirement | Who sets it | What it means for the build |
|---|---|---|
| HIPAA Security Rule | HHS | Encrypted audio and transcripts, access control and an audit log of every view |
| Business Associate Agreement | HHS (HIPAA) | A signed BAA with every speech, model and hosting provider that receives audio or text |
| Recording consent | State law and your policies | Consent captured before recording, and a clear way to stop |
| AI risk management | NIST AI RMF (voluntary) | Documented evaluation, monitoring and a way to pause the scribe |
| EHR write-back | ONC (ASTP) and HL7 International | Notes written through the FHIR APIs certified EHRs offer, or the vendor's interface |
| Billing documentation | CMS | The clinician remains responsible for the note that supports a claim |
Pipeline
How does a visit become a structured note?
Each step is a separate component, so it can be tested, measured and replaced.
1.
Consent and capture
The patient's consent is recorded, then audio is captured on a phone, tablet or exam room device and encrypted in transit.
Consent first2.
Transcription
Speech is transcribed with speaker labels for clinician and patient, using a provider covered by a BAA.
Who said what3.
Note generation
A language model drafts the note in your template, with each statement linked to the transcript it came from.
Linked to source4.
Review and sign
The clinician edits and signs. Nothing reaches the chart without sign-off.
Clinician in control5.
EHR write-back
The signed note is written to the EHR through its FHIR API or vendor interface.
Into the chartBuild or buy
Should you build or buy an AI scribe?
Packaged scribes work for many practices. Building makes sense in specific cases.
Buy a packaged scribe
When it supports your EHR and specialties and its data terms work for you.
Build a custom scribe
When the note format, specialty workflow or EHR integration is part of your product, or you need control over the data and models.
Extend what you have
Add templates, structured data extraction or write-back around a scribe you already use.
Scope and effort
What drives the scope, timeline and cost of an AI scribe?
We do not quote before we understand these.
Specialties and templates
Each specialty adds templates, evaluation and clinician review.
EHR write-back
Which EHRs, and whether notes go back as text or structured data.
Capture setting
Phone, tablet, exam room device or telehealth visits.
AI providers
Which speech and model providers, under which BAAs, or models you host yourself.
Evaluation depth
How many visits clinicians review before and after launch.
Evaluation
How do you measure accuracy and catch hallucinations?
A scribe is only useful if clinicians trust it. We measure it before launch and keep measuring after.
| Check | What it catches | How we run it |
|---|---|---|
| Source linking | Statements with no support in the conversation | Every sentence in the note must link to transcript text, or it is flagged |
| Clinician review | Errors the model cannot see | Clinicians review a sample of notes against the recording during the pilot |
| Omission checks | Important findings left out | Comparison of the note against key items in the transcript |
| Edit tracking | Where the draft is weak | How much clinicians change each section, tracked over time |
| Drift monitoring | Quality dropping after launch | Ongoing sampling and alerts when edit rates or flags rise |
Results are measured against your own clinicians' review, not a vendor's benchmark.
Facts and sources
Which rules and facts shape an AI scribe build?
Short facts we design around, each linked to its primary source.
A HIPAA covered entity may share protected health information with a business associate, such as a software vendor, only under a business associate agreement that commits the vendor to safeguard it.
Source: 45 CFR 164.502(e) and 164.504(e) (eCFR)The NIST AI Risk Management Framework is a voluntary framework that organizes AI risk work into four functions: Govern, Map, Measure and Manage.
Source: NIST AI 100-1The HIPAA Security Rule requires administrative, physical and technical safeguards for electronic protected health information.
Source: 45 CFR Part 164 Subpart C (eCFR)ONC certification criterion 170.315(g)(10) requires certified EHRs to offer a standardized API for patient and population services based on HL7 FHIR.
Source: 45 CFR 170.315 (eCFR)
Frequently Asked Questions
Buy if a packaged scribe supports your EHR, specialties and data terms. Build when the note format or EHR integration is part of your product, or you need control over the data and models. We help you compare the options first.
Audio is encrypted in transit and at rest, processed only by providers under a BAA, and kept only as long as your policy allows, often deleted once the note is signed. Every access is logged.
Notes can be written back to EHRs that offer a FHIR API or a vendor interface for documents, including Epic and Oracle Health. Write access needs the vendor's and your organization's approval, which we plan for early.
No. The scribe drafts; the clinician reviews, edits and signs. Nothing is written to the chart without sign-off.