What comes in
Finished encounter note
- The clinician documents a lab order and a specialist referral.
- The note contains the details required for the next steps.
Clinical Documentation
Put the note’s details where they belong.
Caesar turns finished notes and outside records into structured EMR entries. Documented orders and chart updates reach the right place for review, so your team spends less time entering the same details again.
- Works with existing notes
- Clinical items prepared for review
See the work
Read once. Prepare the chart updates.
The sample flows below use documented decisions. They do not create a diagnosis or treatment plan.
What comes next
Items prepared for review
- The lab order is staged in the order module.
- The referral details are prepared for the referral workflow.
The clinician reviews the prepared items before they proceed under the practice’s rules.
What Clinical Documentation does
- 1Read finished note
- 2Extract decisions
- 3Prepare entries
- 4Review and approve
What comes in
Outside record
- A received document contains medication information.
- One entry differs from the existing chart.
What comes next
Reconciliation review
- The difference is flagged for the clinical team.
- The source information remains available to verify the entry.
Staff can resolve the discrepancy before accepting the chart update.
What Clinical Documentation does
- 1Read source
- 2Extract medication
- 3Compare record
- 4Flag for review
What it handles
Finish the chart work behind the note.
A completed narrative still leaves fields to fill and actions to prepare. Caesar reads the documented decisions and places their details in the connected chart.
Prepare documented orders
Extract lab or imaging orders from the note and stage them in the appropriate module.
Update chart fields
Turn documented findings into discrete entries for the problem list and other structured fields.
Flag medication differences
Compare documented medication information with the chart and surface discrepancies for review.
Use existing records
Read historical notes and scanned documents so their clinical details become searchable structured data.
Fits your practice
Start with the note you already have.
This agent can work after the AI Scribe or on documents created elsewhere.
- 1
Read the source
Take in a finished note, provider memo, or outside clinical document.
- 2
Find the details
Extract documented clinical information and the decisions recorded by the provider.
- 3
Prepare chart entries
Map details to supported fields and stage the appropriate orders or referrals.
- 4
Review and route
Send prepared entries through the practice’s clinical review and sign-off process.
Documented decisions come first.
The agent structures information already present in the record. It does not choose a treatment. Orders and prescriptions can be staged for provider sign-off, and medication discrepancies are flagged for a clinician to resolve.
- Keep provider review for clinical orders and prescriptions.
- Check discrepancies against the source record.
Keep your existing system.
We confirm the available connections and functions in your electronic medical record system, or EMR, before setup.
Check your EMR integration
Available functions vary by system and agent.
Before you start
Your questions, answered.
What to expect from Clinical Documentation, and what your team controls.
How is this different from the AI Scribe?
The AI Scribe writes the encounter narrative. Clinical Documentation reads the finished note and prepares structured EHR entries: lab orders, prescriptions, referrals and chart fields. It works with Scribe notes and documents created elsewhere.
Does the agent place orders and prescriptions on its own?
It extracts documented orders, prescriptions and referrals and stages them in the appropriate module, including e-prescribing. Your practice sets review and sign-off requirements. The agent does not choose tests, diagnoses or treatment.
Can it structure our years of legacy notes?
Yes. It processes historical free-text notes, scanned discharge summaries and faxed outside records. Clinical NLP turns documented information into searchable, coded data for care, quality measures and analytics. Provider voice memos can also become structured chart entries.
Which coding standards and data formats does it use?
It maps clinical concepts to SNOMED CT, ICD-10, CPT and RxNorm. FHIR-compliant structured output supports exchange with connected systems. We confirm the code mapping and destination fields required by your EMR.
Which EHRs does it integrate with?
It reads documents and writes structured entries in supported EHRs including Epic, athenahealth, eClinicalWorks and NextGen, as well as connected document management systems. Available modules and write-back fields are confirmed before rollout.
Is the Clinical Documentation Agent HIPAA compliant?
Yes. The Clinical Documentation Agent runs on HIPAA-compliant infrastructure. Data is encrypted in transit and at rest. Caesar Health executes a Business Associate Agreement (BAA) at contract signing. SOC 2 Type II is in progress.
Which chart fields can it prepare?
Documented vitals, results and statuses can populate discrete fields. It can update the active problem list and compare patient-reported medications with the chart, flagging discrepancies for reconciliation. Documented lab, imaging and procedure orders are routed to their supported modules for review.
How does clinical documentation automation reduce repeated EHR data entry?
A narrative note can contain a lab order or referral while the corresponding EHR field is still empty. The agent extracts that documented decision and prepares the entry in the right module. Your clinician reviews the prepared items instead of retyping the same information.
Clinical Documentation
Take the repeat entry out of documentation.
Show us what your team enters after the note is finished. We will map the supported chart updates and review steps.
Book a demo