📝 AI Clinical Documentation

AI Progress Notes for Clinical Documentation

Turn every clinical conversation into complete, compliant AI progress notes in seconds. HealOS captures visits, understands medical context, and generates structured documentation in SOAP, DAP, BIRP, H&P and 50+ formats ready to drop into your EHR.

Spend less time typing and more time with patients.

AI Progress Notes for Clinical Documentation

The Problem. The Impact. The HealOS Solution.

Traditional clinical documentation creates burnout, errors, and lost revenue. HealOS AI progress notes solve these challenges with automated, accurate, compliant documentation.

ChallengeImpact on Care & RevenueHealOS Progress Notes Solution
Typing notes after clinicLate nights, burnout, and backlogged chartsAI progress notes created automatically during or right after visits
Inconsistent documentation qualityRisk of denials, audit issues, and gaps in careStructured templates that keep every AI clinical note payer-ready
Splitting focus between screen and patientLower patient satisfaction and missed detailsAmbient AI listens in the background while you stay present
Different formats across cliniciansDisconnected care and messy recordsStandardized SOAP / DAP / BIRP formats across the whole team
Manual EHR entryDuplicate work and copy-paste errorsOne-click export of AI clinical documentation straight into your EHR

Challenges in Traditional Clinical Documentation

Hours of After-Visit "Pajama Time"

Clinicians often spend two hours charting for every hour with patients. This drives burnout and reduces patient capacity.

Inconsistent, Non-Standard Notes

Different note styles across providers create audit risk and make it harder to see progress over time.

Limited Time for Patients

Typing while patients talk hurts rapport. Important details get lost when clinicians cannot stay fully present.

Complex Medical Terminology

General dictation tools struggle with diagnoses, medications, and abbreviations, forcing manual corrections in every note.

Fragmented Tools and Workflows

Telehealth, EHR, dictation, and templates live in separate apps, forcing constant copying, pasting, and re-work.

Proven Outcomes with AI Progress Notes

10+ Hours
Saved Weekly
Clinicians reclaim 10+ hours every week by replacing manual charting and after-hours paperwork with AI clinical documentation.
98%
Clinical Accuracy
AI trained on medical vocabulary delivers 98% accuracy for transcription, summaries, and structured AI progress notes.
50+
Note Formats Supported
Generate SOAP, DAP, BIRP, GIRP, H&P, intake, psychiatry, and specialty-specific formats from a single session recording.
60–80%
Faster Documentation
Most providers cut per-patient documentation time by 60–80%, without sacrificing clinical quality or compliance.

AI Progress Notes & Clinical Documentation Features

Everything you need to automate clinical documentation and generate compliant progress notes in seconds.

1

Real-Time Transcription & Note Drafting

HealOS listens securely to in-person or virtual visits, transcribes the conversation, and drafts AI progress notes in real time. You review and approve instead of starting from a blank page.

2

Multiple Note Format Support

Generate AI clinical documentation in SOAP, DAP, BIRP, GIRP, H&P, intake, psychiatry, pediatric, and custom templates. Keep every payer and specialty covered without building formats from scratch.

3

Medical Terminology & Clinical Context

The HealOS engine understands ICD-10 codes, medications, labs, behavioral health language, and specialty phrases. It recognizes who is speaking, what is clinically relevant, and how to phrase it in professional documentation.

4

Natural Language Understanding (NLU)

AI identifies symptoms, history, assessment, risk factors, goals, and plan. It turns free-flow conversation into clear sections that match your preferred progress note style.

5

EHR Integration & Seamless Workflow

Use a browser extension or direct integration to move AI progress notes into Epic, Athenahealth, DrChrono, Kareo, NextGen, and other major systems. No duplicate typing or downloading required.

6

Custom Templates & Specialty Workflows

Adjust tone, length, and structure to match your clinic's guidelines. Build templates for therapy, psychiatry, primary care, cardiology, pediatrics, surgery, and more, then let AI populate them automatically.

7

HIPAA-Compliant, Zero-Storage Security

HealOS encrypts all data in transit and at rest. Recordings can be deleted automatically after notes are generated, so AI clinical documentation never requires long-term audio storage.

8

Compliance & Audit-Ready Notes

Built-in checks ensure AI progress notes include medical necessity, interventions, response, and plan. Documentation aligns with payer and state guidelines, helping you stay audit-ready.

9

Session Summaries & Key Insights

Get high-level session summaries, key risks, goals, and follow-up tasks extracted automatically. Perfect for quick catch-up before the next visit.

10

Multilingual & Cross-Specialty Support

Support visits in English and additional languages while still generating AI clinical documentation in your preferred format. Ideal for diverse patient populations and multi-site health systems.

How HealOS AI Progress Notes Work

HealOS combines ambient listening, medical NLU, and template-driven outputs to automate clinical documentation from start to finish.

1
Step 1

Capture the Visit

Start a session from the HealOS app, browser extension, or telehealth integration. With patient consent, HealOS records audio and begins live transcription.

2
Step 2

Understand Clinical Context

AI identifies speakers, extracts clinically relevant details, and maps them to history, mental status, assessment, risk, and plan. Non-clinical small talk is ignored.

3
Step 3

Generate Structured AI Progress Notes

Within seconds, HealOS drafts a complete note in your chosen format, SOAP, DAP, BIRP, or custom. Diagnoses, interventions, and goals are clearly documented.

4
Step 4

Review, Edit, and Approve

You skim, make quick edits if needed, and approve. The system learns from your edits, improving future AI clinical documentation in your style.

5
Step 5

Sync to EHR & Billing

Export the final note into your EHR with one click. Notes stay linked to the correct patient, encounter, and billing data to support clean claims and audits.

6
Step 6

Track Progress Over Time

HealOS surfaces trends across sessions, symptom changes, goal progress, risk factors, so every AI progress note contributes to a clear picture of patient outcomes.

Key Benefits of AI Progress Notes with HealOS

Transform your clinical documentation workflow with AI that saves time, improves quality, and enhances patient care

Financial & Operational Benefits

Save 10+ Hours Weekly

AI progress notes replace late-night charting and weekend catch-up with minutes of review per visit.

Financial & Operational Benefits

See More Patients Without Burnout

Recovered time can be used for additional visits, supervision, or rest—without sacrificing documentation quality.

Financial & Operational Benefits

Standardize Documentation Across the Team

Use shared templates so every clinician's AI clinical documentation meets the same standard.

Clinical & Patient Experience Benefits

Be Fully Present in Session

Spend time observing, listening, and connecting—not typing. AI handles the notes while you focus on care.

Clinical & Patient Experience Benefits

Higher-Quality Records

Notes are complete, structured, and clinically detailed, supporting safer decisions and better continuity of care.

Clinical & Patient Experience Benefits

Better Follow-Up and Treatment Planning

Clear documentation means easier treatment reviews, referrals, and cross-team collaboration.

Compliance & Security Benefits

HIPAA-Compliant by Design

Encrypted workflows, access controls, and detailed audit logs keep AI clinical documentation secure.

Compliance & Security Benefits

Audit-Proof Documentation

Progress notes consistently capture medical necessity, risk, interventions, and outcomes.

Compliance & Security Benefits

Zero-Storage Options

Choose automatic deletion policies for recordings to minimize PHI exposure.

Why Providers Choose HealOS Over Generic AI Note Tools

HealOS is built exclusively for healthcare, delivering the reliability, accuracy, and compliance medical practices need to deliver exceptional clinical documentation.

🏥

Built for Healthcare, Not General Dictation

HealOS is trained on medical and behavioral health language, payer rules, and clinical note structures.

🔄

End-to-End Clinical Documentation Automation

From ambient capture to AI progress notes to EHR export, everything lives in one workflow.

⚡

Fast Setup, Minimal Change Management

Most teams start generating AI progress notes in under 30 minutes with existing devices and workflows.

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Enterprise-Grade Security & Governance

Role-based access, audit logs, and strict PHI controls make HealOS safe for solo practices and large systems.

Frequently Asked Questions

Everything you need to know about AI progress notes and clinical documentation automation

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