Medical record documentation and coding

Step-by-Step Breakdown

Detailed explanation of each automated stage in the workflow.

1. 1

   Trigger

   Patient examination completed

   Dermatologist finishes patient visit and uploads clinical photos with initial findings to DermEngine. System detects completion status and initiates documentation workflow.

   DermEngine
2. 2

   Action

   Extract clinical data elements

   AI analyzes uploaded images and extracts key clinical findings including lesion characteristics, anatomical locations, and diagnostic indicators. System pulls structured data from examination notes.

   DermEngine3DermSystems
3. 3

   Decision

   Determine documentation complexity level

   System evaluates visit complexity based on number of lesions examined, procedures performed, and diagnostic complexity. Routes to appropriate documentation template based on billing level requirements.

   Epic EHR
4. 4

   Action

   Generate automated clinical notes

   AI creates comprehensive SOAP notes using structured templates, incorporating image analysis findings, patient history, and examination details. System ensures medical necessity documentation for procedures.

   Epic EHRModernizing Medicine EMA
5. 5

   Action

   Assign ICD-10 diagnostic codes

   System automatically maps clinical findings to appropriate ICD-10 codes based on documented diagnoses and lesion characteristics. AI validates code accuracy against clinical documentation.

   Epic EHRModernizing Medicine EMA
6. 6

   Action

   Quality review and validation

   Automated system performs final quality check on documentation completeness, coding accuracy, and billing compliance. Flags any inconsistencies or missing elements for provider review.

   Epic EHR
7. 7

   Output

   Finalize documentation package

   System generates completed medical record with clinical notes, diagnostic codes, and supporting images ready for provider approval and billing submission.

   Epic EHRModernizing Medicine EMA

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