EMRSystems

Clinical Documentation

AI-native clinical documentation built for providers

Reduce charting time by 38% with EMRSystems' clinical documentation software. Streamline clinical workflows with AI ambient scribing, customizable templates, and HIPAA compliance.

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Why teams choose us

Built for the way clinicians actually work

Every workflow is designed with input from practicing physicians, nurses, and practice managers — so you spend less time clicking and more time with patients.

  • Ambient AI Scribe draft notes automatically in real time
  • Specialty-specific documentation templates loaded in one click
  • IMO clinical terminology maps ICD-10 & CPT codes instantly
  • Voice dictation, shorthand macros, and custom dot-phrases supported

Capabilities

What you get

Ambient AI Scribe

Securely listen to patient conversations and automatically draft highly structured SOAP notes for your review, complete with history, physical exam, and plan elements.

Specialty Templates

Access pre-configured clinical documentation templates built specifically for over 20 medical specialties. Easily customize layouts to suit your exact charting habits.

Intelligent Suggestions

Our documentation engine reads your clinical narratives in real time to suggest highly accurate ICD-10, CPT, and HCC codes, streamlining billing workflows and preventing claim rejections.

Voice-to-Text

Integrated cloud-based medical voice dictation allows you to speak your notes directly into any field of the patient's electronic health record, with medical term dictionary support.

Shorthand & Dot Phrases

Create and share custom templates, shorthand codes, and dot phrases (`.normalexam`) to populate repetitive paragraphs, physical exams, and common assessment plans in seconds.

Decision Support

Get real-time preventive health notifications, screening recommendations, and medication interaction warnings directly in the clinical charting screen during patient documentation.

FAQ

Frequently asked questions

Is the Ambient AI Scribe secure and compliant?
Yes. The ambient audio is processed fully in compliance with HIPAA guidelines, using secure transit protocols. No audio is stored on our servers once the clinical note is successfully generated, ensuring absolute patient privacy.
Can I import templates from my current EMR?
Yes. Our migration team will help you map and rebuild your current physical examination templates, review of systems, and custom templates into EMRSystems prior to going live.
Does it work on a mobile phone or tablet?
Absolutely. EMRSystems has native iOS and Android apps with full charting capabilities, speech-to-text dictation, and document upload features so you can chart from anywhere.
Does the charting tool suggest billing codes?
Yes. The system parses your clinical documentation in real time and automatically suggests the most accurate ICD-10 diagnosis codes and CPT procedure codes to maximize reimbursement efficiency.

Ready to see EMRSystems in action?

Book a 30-minute personalized demo. No commitment, no credit card.

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