The chart and clinical notes
A chart that shows who wrote every word and when — SOAP notes with each line attributed to the AI draft, the doctor or the intake form, a signed note that locks the chart and keeps every later change with its author, allergies on the chart beside the prescription, and the AHCIP claim built from the same record.
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The note
Every line knows where it came from. Run down a note and it tells you which words were the AI draft, which the doctor wrote, and which came from the intake form the patient filled at home. A history summary sits at the top — prior visits, allergies, current prescriptions — before anything is written.
Signing
Signing locks the whole chart. From then on it is a record rather than a draft: every later change keeps the original and says who made it, and the note is attributed to the clinician who signed it, with the time.
What is in the room
Allergies sit on the chart beside the prescription, not two clicks away in a tab nobody opens under time pressure. Encounters, prescriptions, requisitions, allergies, imaging and vitals share one patient timeline with the day's calendar.
A family in one visit
A group booking opens one encounter with a separate record per person, each keyed to their own patient ID. Four people, four charts, one visit — nothing written on one lands on another.
What the chart feeds
The AHCIP claim is built from the signed encounter (Alberta), the patient portal shows the same words you wrote, and the AI features draft into the same box you would have typed into. Lab results landing on the chart, PACS and inbound fax are marked Soon and are not available yet.
Where to look