Automated Clinical Documentation
An AI-driven clinical solution that seamlessly records and documents patient interactions with precision and efficiency at the point of care.
Focus on patients, not paperwork
Instantly transforms patient-doctor conversation into organized clinical notes in real-time at the point of care. With Shaip Automated Clinical Documentation Solution – Enhance clinician Satisfaction, patient experiences, operational productivity, and financial performance.
Explore how we can help
For Clinicians
Eliminate burnout and create more time for patient care.
For Enterprise
Extract value from the start of each dialogue.
For Patients
Simplify patient engagement in their health management.
Experience the Advantages of an AI-Powered, Voice-Activated, Ambient Clinical Intelligence Solution
Our solution automatically captures patient interactions with accuracy and efficiency at the point of care. It surpasses the performance of a virtual or in-person scribe and can be affordably expanded throughout your organization to enhance the healthcare experience for both clinicians and patients.
Advanced Speech Recognition – Utilize state-of-the-art automated speech recognition (ASR) technology to accurately capture the natural dialogue between healthcare providers and patients.
Multi-Party Conversation Recording – This app enables healthcare professionals to naturally converse with patients and families, securely recording these talks at the point of care, fostering patient interaction and reducing clinician screen time.
Fine-Tune Dictations – Gives healthcare providers the ability to oversee and refine their final documentation, transforming spoken dictations into meaningful clinical notes.
Automated Clinical Documentation – Converts medical conversations into detailed, specialty-focused clinical summaries, rapidly accessible for healthcare provider review and adjustment.
Personalized Templates – Clinicians have the option to tailor and adjust note templates, ensuring uniformity and an optimized workflow that meets individual requirements. Effortless Integration with EHR Systems – Simplifies the process of integrating AI-generated notes into various EHR systems, ensuring seamless data entry and management.
Designed for Healthcare – Developed and refined using millions of authentic clinical dialogues with patients, this system employs the latest AI technologies to efficiently and consistently generate precise documentation
Generating SOAP Notes from Doctor-Patient Conversations
SOAP Note Example
Subjective
The patient is an xx-year-old male, accompanied by his wife, who presents today for an acute visit. He complains of a tingling pain in his bruised right shoulder associated with numbness swelling. His pain started last week s/p an injury
while playing baseball. He has tried Tylenol without any significant benefits and has swelling and pain has worsened. He had a shoulder dislocation but did not think it would heal over time. He has tried stretching exercise to put in place. He inquires if an ice pack application can help his pain. He also has mild pain and swelling on his right knee resulted from the same injury. His BP was optimal at 118/66 mmHg but his heart rate was elevated at 90 bpm. He does not have any significant medical history. He stays active usually, plays baseball with friends every week, until last week. He denies having any vision changes lately. He also denies any respiratory issues including asthma. Denies having any known history of hyper or hypotension. He does not have any digestive issues. He has a healthy dietary habit including fruits and vegetables. He also stays hydrated. He denies any having any known food & drug allergy. He has his wife at home to help him in his need.
Objective
- Senses are intact in his right finger.
- Tenderness was noted with abduction of his right arm. The right shoulder was found to be intact in place. ROM is possible but with pain.
- Bruising was noted on his right knee. Senses intact. ROM is possible but with pain.
Assessment
- Right shoulder pain
- Right knee pain
Plan
- Fixed a sling to his right arm to restrict his shoulder movement and support healing.
- Prescription was sent for ibuprofen 800 mg of; benefits and adverse effects were discussed. Informed him that ibuprofen will also help him with his pain in knees. Advised to report if the pain worsens, we will prescribe naproxen for him.
- We will try conservative management at this point, and he is unlikely to require a surgery.
- Advised to avoid playing baseball until it heals properly. Assured him that his pain should alleviate in 1-2 week and can start with his mobility.
- Assured him that his shoulder is in place and we do not require an X-ray at the moment.
- Informed him that ice pack may help her numb the pain to some degree but advised not to use a warm compress
and he can put off the sling while sleeping but cautioned not to sleep on the affected shoulder. - Informed him that he does not a need an antibiotic therapy.
- Advised to avoid driving and strenuous activity until it heals properly.
- Referral provided to physical therapy to assess the need for it.
Follow up in 2 weeks to reassess.
Summarization Template
Subjective: Middle-aged male with a week-old right shoulder injury from baseball, experiencing tingling pain, numbness, and swelling. Pain relief from Tylenol is minimal. No significant medical history, healthy lifestyle, and no known allergies.
Objective: Intact sensation in right fingers, pain and tenderness in right shoulder & knee with limited range of motion.
Assessment: Right shoulder and knee pain due to injury.
Plan: Applied sling for shoulder support, prescribed ibuprofen, advised against strenuous activities, and suggested ice packs for pain relief. No surgery needed; no X-ray or antibiotics required. Advised caution while sleeping and against driving until healed. Referral to physical therapy given, with a follow-up in 2 weeks.
Elevate Your Healthcare Journey
Explore the revolutionary impact of AI-driven healthcare solutions for clinicians, patients, and healthcare institutions.
Top-Tier Privacy and Security
Our Automated Clinical Documentation solution is built with strict safeguards to ensure total protection and privacy.
- Advanced encryption methods
- Safe data storage
- Compliance with HIPAA and GDPR
- Clear privacy rules
Featured Clients
Empowering teams to build world-leading AI products.
