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AI Agent
v2.0.4
FHIR R4 Validated
HIPAA Ready

Clinical NLP Documentation Assistant

Turn clinician speech into structured FHIR R4 documentation in real time

by HealthData Labs
4.6(156 reviews)
2,300 deployments

About

The Clinical NLP Documentation Assistant from HealthData Labs uses a fine-tuned clinical language model to transcribe ambient provider-patient conversations and extract structured entities: diagnoses (ICD-10), medications (RxNorm), procedures (CPT), and clinical observations (LOINC). The assistant generates FHIR R4 Composition (clinical note), Condition, MedicationStatement, and Observation resources automatically, then presents a draft for physician review and attestation. Deployed at 42 health systems, it has reduced average documentation time from 14 minutes to 4.5 minutes per encounter while improving completeness scores by 34%.

Key Features

  • Ambient voice capture with specialty-specific clinical language models
  • Named entity recognition for diagnoses, medications, procedures, and observations
  • Structured FHIR R4 output: Composition, Condition, Observation, MedicationStatement
  • Physician draft review and attestation workflow

68%

-68%

Documentation Time Reduction

+34%

Note Completeness Score

94.3%

Entity Extraction Accuracy

91.8%

ICD-10 Coding Accuracy

4.5 min

-68%

Avg. Time Per Encounter

4.7 / 5

Clinician Satisfaction

HIPAA BAA included with all enterprise plans

Compliance

HIPAA BAA
SOC 2 Type II
ONC Certified Health IT
HITRUST CSF

Tags

Clinical NLP
Ambient Documentation
FHIR R4
AI Agent
EHR Integration
Structured Data
Voice
CategoryClinical Documentation
Versionv2.0.4
UpdatedDec 8, 2025
FHIR VersionR4