Generating clinical documentation using large language models and artificial intelligence

Abstract

Systems and methods generate clinical documentation using large language models and artificial intelligence (AI). A template management module is provided to create customizable templates. A processing unit can receive input data from various sources and use AI to generate transcripts, summarize sessions, and produce clinical documentation such as clinical notes. The processing unit may also generate Current Procedural Terminology (CPT) and diagnosis codes, generate after-visit summaries, and generate referral letters. The AI may be trained on past clinical notes and can adapt to the clinician's style over time, with a feedback loop for continuous improvement. Additional features include cohort-based training, real-time language translation, predictive text, and analytics for documentation trends. The system supports customization of note length, style, and keywords, as well as integration with external medical databases and patient portals.