Drafts structured clinical notes from the encounter, closes documentation gaps, and writes back to the EHR — running entirely inside your infrastructure.
The Clinical Documentation Agent is an autonomous AI agent that turns the clinical encounter into structured, billable documentation — SOAP notes, summaries, and CDI prompts — and writes it back to the EHR.
It works from ambient audio or structured inputs, reasons over the visit and the patient record, and surfaces gaps that affect coding and quality, without a scribe transcribing each visit.
This is not a transcription tool that hands back raw text. It is an active agent that drafts, structures, and improves documentation, deployed air-gapped or on-premise so PHI never leaves your environment.
A documentation chatbot rewrites text you paste in. The Clinical Documentation Agent captures the encounter, drafts the structured note, flags CDI gaps, and posts it to the EHR — autonomously, across the full clinic schedule.
The Clinical Documentation Agent is a true AI agent that goes beyond simple Q&A. It reasons, plans, and executes multi-step workflows autonomously while you retain full code ownership and infrastructure control.
Generates SOAP notes, H&Ps, and visit summaries from ambient audio or structured encounter inputs, formatted to your templates.
After a visit, the agent drafts the structured note and stages it in the EHR for the clinician to review and sign.
Identifies specificity and completeness gaps that affect coding, severity capture, and quality measures.
Surfaces a concurrent CDI prompt during charting — for example, missing acuity or laterality — instead of catching it weeks later in a retrospective review.
Aligns the note with the active problem list, medications, and orders to keep the record internally consistent.
Flags discrepancies between the documented assessment and the active problem list and proposes reconciliation.
Structures documentation so downstream coding can assign accurate ICD-10 and CPT codes without back-and-forth queries.
Hands a coding-ready note to the Medical Coding Agent, reducing physician queries after the fact.
Produces patient-facing visit summaries and after-visit instructions in the patient's preferred language.
Generates the after-visit summary automatically and routes it to the patient portal in the right language.
The agent ingests ambient audio or structured encounter data along with the relevant chart context from the EHR.
It organizes the encounter into a structured, template-conformant note, identifying documentation and specificity gaps as it goes.
The agent drafts the note, raises concurrent CDI prompts where needed, and stages the documentation in the EHR for clinician review and signature.
It checks the signed note against quality measures and coding readiness, learning from edits clinicians make.
The agent logs a complete audit trail and produces patient summaries, while reporting documentation quality and clinician time saved.
Cut documentation time per clinician by roughly two hours a day and improved severity capture, with PHI staying on-premise.
Reached near-100% same-day note completion and reduced pajama-time charting.
Standardized session documentation while keeping highly sensitive notes entirely inside the practice.
Improved documentation completeness and reduced downstream coding queries.
Deployed air-gapped, supported teaching-physician rules, and freed faculty time for supervision and care.
Reads chart context and writes structured notes, after-visit summaries, and CDI prompts into Epic's documentation workflow.
Pulls encounter context and posts drafted documentation back into Oracle Health for clinician review and signature.
Drafts and stages ambulatory visit notes and patient summaries within athenahealth.
Integrates with MEDITECH Expanse to draft and reconcile documentation against the chart.
Routes multilingual after-visit summaries and instructions to the patient portal automatically.
Hands coding-ready notes to the Medical Coding Agent to reduce queries and accelerate billing.
You receive the complete codebase. Your documentation infrastructure is yours to audit, modify, and operate permanently.
Deploy entirely within your own infrastructure so PHI and recorded encounters never leave your perimeter.
Run on AWS, Azure, Google Cloud, or your own data centers. ibl.ai is a certified partner of all three hyperscalers.
Choose the model that fits your accuracy and residency needs and swap it without rebuilding documentation workflows.
No patient data is sent to ibl.ai. Every draft and edit is logged to your own immutable audit trail for HIPAA and quality review.
Clinicians reclaim roughly two hours per day previously spent on after-visit charting.
Autonomous drafting drives same-day note completion rates close to 100%.
Coding-ready, specific documentation cuts retrospective physician queries roughly in half.
Reducing pajama-time charting is consistently linked to lower clinician burnout and turnover.
Enterprise-wide flat-fee licensing eliminates per-clinician scribe SaaS pricing.
See how ibl.ai deploys autonomous AI agents you own and control — on your infrastructure, integrated with your systems.