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Count the layers of the Clinical Reasoning Layer
The purpose of clinical reasoning is to evaluate the signs and symptoms of a patient, develop a diagnosis from the patient’s reported signs and symptoms and arrive at an appropriate management plan to treat the underlying condition or issue. Many clinicians have traditionally listed the signs and symptoms for a patient but have not carefully interpreted each of those signs and symptoms.
The Clinical Reasoning Layer captures the core elements of the human diagnostic thinking process and helps to create an accurate diagnosis based on a combination of all sign and symptom observations.
The term clinical reasoning refers to the processes performed by clinicians when evaluating patients. The components of clinical reasoning include but are not limited to the following:
- Assessing a patient's symptoms
- Recognizing patterns
- Making a differential diagnosis
- Drawing clinical conclusions
- Making evidence-based decisions
Many existing tools rely heavily on physician experience and expertise. In contrast, Carevyn integrates those same processes into its artificial intelligence (AI) model to provide clinical documentation support; however, it does not replace clinicians performing this task.
Why This Layer of Carevyn AI is Important
Most current AI documentation solutions simply record text (e.g. dictation or note-taking) without being able to capture context. Current AI solutions can take notes on what has been verbally communicated by the patient, but do not have the capabilities to understand what the data represents in terms of making clinical decisions. Carevyn provides a completely new standard in the performance of clinical documentation: Carevyn builds a clinical documentation note that is based on reasoning, as opposed to only transcription.
With Carevyn, the patient narrative, clinician questioning, medical history, and examination observations are all reviewed in conjunction with one another. Subsequently, diagnostic reasoning is used to reconstruct the data as appropriate.
AI Clinical Documentation with Real-World Intelligence
Traditional dictation tools and simple note-taking assistant applications do not have the capability to provide deeper insights and analyses into the information being captured. Carevyn has created a system that allows for intelligent integration of clinical information into a comprehensive and clinically relevant information structure.
Carevyn is able to understand:
- The reason for a patient's complaint
- How a patient's symptoms relate to possible diagnoses
- What additional questions a clinician would be likely to ask
- Which risk factors should be included in the documentation
- How to properly structure a SOAP documentation note with the greatest level of precision
Carevyn is designed to collect information from a patient when they say "I have chest tightness". Then based on a variety of data, it will make an informed decision as to whether or not cardiac is the most reasonable diagnosis. The same holds true with pulmonary concerns, red flags etc. This type of reasoning cannot be obtained from transcription tools that simply transcribe the word spoken by the provider.
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Carevyn turns real-world clinical intelligence into smarter, clearer documentation—automatically
AI that thinks like a Provider
Carevyn doesn't simply record a provider's comments, it interprets the underlying intent of the comment.
As a result, the Carevyn notes have a much closer alignment to the clinical logic of the provider and they include:
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A structured HPI
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Relevant Review of Systems
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Appropriate PE Findings
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Evidence-based Assessment and Differential Diagnoses.
As a result, Carevyn documentation achieves both the accuracy and speed that Clinical Documentation requires.
The Clinical Reasoning Layer and its Impact on Increasing the Precision of Diagnosis
Carevyn's intelligence relies on the process of Diagnostic Reasoning which is the same way that clinicians use to evaluate cases where there are multiple competing factors.
Pattern Recognition and Symptom Mapping
To support the clinician, Carevyn links Patient's Reported Symptoms to Clinical Frameworks such as:
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ICD-10 Classes
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Common Diagnosis Pathway
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Assessments of Risk
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Evidence-Based Guidelines
With the above understanding Carevyn can put together a list of the information that will most likely need to be in the Clinician's documentation.
Built-In Clinical Decision Support AI
Carevyn is like a Personal Assistant to the Provider, listening, processing, and making decisions based on the information received in the moment. Carevyn does not give medical advice but it uses its ability to process information in real time to provide the most helpful information to the Provider.
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Transforming Clinical Workflows Through Automation
By utilizing advanced automation in clinical workflows, Carevyn addresses a major source of clinician burnout - administrative overhead. With Carevyn's solutions, a clinician can now eliminate repetitive documentation tasks and focus on patient care, as opposed to spending considerable time on a computer. By automating critical areas of the clinical workflow, such as SOAP note creation, summarising patient encounter notes, extracting keywords for diagnoses, supporting clinical coding, completing formal encounter documentation and creating follow-up plans, Carevyn promotes efficiency and provides consistency across the board, reduces the likelihood of errors related to compliance issues, and decreases time spent typing your documentation late at night or on weekends.
Carevyn listens in on conversations between clinicians and patients during the encounter. This way, it collects information, categorises it according to subject matter, extracts only pertinent information for clinical purposes, and converts all dialogue into a structured format for documentation. When the appointment is over, the clinician has the benefit of receiving a polished set of medical notes that have been generated with the least possible effort after hours.
What Does Carevyn Have That Other Documentation Tools Do Not?
Carevyn provides medical professionals with a framework for evaluating and documenting clinical information using documented structured reasoning skills that result in greater accuracy in interpreting the contextual meaning of a patient's statement(s) and aligning them to the physician's intent to document care. Carevyn also provides the practitioner(s) with an accurate terminology description of the terms used within the notes that, when combined with clinical correlation and proper diagnostics, provide a reliable documentation method that is representative of traditional clinical practice. The manner in which Carevyn captures the clinical thought process provides practitioners with a clear understanding of the documentation generated based on documented findings and how clinical reasoning occurs throughout the medical record.
Here is what makes notes created by Carevyn so high quality:
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Contextual Understanding: The Carevyn system captures the reasons behind patient narratives and aligns all documentation with clinical objectives.
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Medical Accuracy: The Carevyn system ensures that every note is medically accurate, reflecting the correct terminology, diagnosis, and symptom analysis.
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Logical Flow Notes: Created by Carevyn consistently follow established clinical patterns, which allows other healthcare providers to easily follow the logic of the notes.
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Evidence-Based Structure: The Carevyn system incorporates clinical evidence and supports clinical decision-making with clinical guidelines and diagnostic frameworks.
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Reduced Ambiguity: The Carevyn system eliminates ambiguity by eliminating unnecessary information from notes, resulting in clean and concise notes that are easy to understand and use.
Clinical Reasoning Examples
A patient presents with the complaint: “I feel like I am tired all the time, and my heart races sometimes.” While AI may only transcribe this information without any understanding or interpretation, Carevyn's understanding of the implications of this patient's statement demonstrates the clinical reasoning that could apply to future Patient complaints of fatigue.
Fatigue could indicate anemia, hypothyroid disease, cardiac dysfunction, or possibly related to depression. A heart racing could need to be evaluated further for arrhythmias or other cardiovascular issues.
Benefits Assumed by Clinicians and Healthcare Systems
The incorporation of clinical reasoning into AI-generated documentation will create a cascading benefit for all stakeholders in the healthcare delivery process:
For Clinicians:
The reduction of administrative burden on clinicians by eliminating redundant data entry. The elimination of the need to complete charts after hours, by taking away the need for clinicians to complete their documentation immediately following patient visits. The elimination of confusion regarding differential diagnoses, because clinical reasoning will allow for clear and concise diagnostic clarity. Facilitation of the desire to create a seamless workflow for clinicians.
For Healthcare Systems:
The delivery of high-quality documentation. The reduction of coding errors and the improvement of billing accuracy. Compliance with all regulations and standards for documentation.
For Patients:
More time spent with the clinician and clearer explanations regarding their diagnosis with, more accurate medical histories.
The Future of Clinical Documentation
We are entering an era where the manual take of clinical notes will soon be replaced by intelligent systems that not only help us document what we see, but also assist us in developing logical clinical reasoning, improving accuracy, and improving efficiency. The Clinical Reasoning Layer represents the future of clinical documentation, which will move the documentation process from a record of the clinical encounter to an interpretation of the clinical encounter using AI technology. Since AI technology continues to evolve, Clinical Reasoning will continue to develop as well.
Time for Providers?
Providers can use Carevyn to document clinical notes in a fraction of the time compared to traditional methods.
Carevyn's Proven Record of Helping Providers With Clinical Note Documentation
For nearly twenty-five years, thousands of clinicians have benefited from Carevyn's mission to create an easier, less stressful and more efficient way to document patient care.
We believe that when you create a world-class product that meets the needs of your customers first, you create a community of loyal customers who will refer you to their colleagues.
Carevyn's Clinical Reasoning Layer was designed and developed with input from clinicians like yourself and is constantly evolving to meet the ongoing need for accurate, clinically relevant documentation.
Carevyn Has the Solution to Help You Reduce Burnout
If you're ready to take care of your documentation; reduce your workload; and become more successful at your practice, then Carevyn is your next step.
Try Carevyn now to revolutionize the way you document care!
Schedule a demo to see our Clinical Reasoning Layer in action.