Clinical Documentation Intelligence

The care was delivered. Make sure the note says so.

One last look before you sign. ChartPilot reads your note, asks about the work you already did, and writes it up in your words — never adding a clinical fact you didn't confirm.

~30s: Per note, before you sign
3–5: Targeted questions, not a checklist
0: Facts invented, ever

Safety checkTroponin result

Diagnostics records the troponin as negative, but the MDM describes it as positive and diagnoses NSTEMI on that basis.

Which result is correct?

YesNo

Documentation creditEKG interpretation

~0.17 wRVU

Your note says an EKG was obtained, but not what you read on it.

Did you interpret it yourself?

Coding snapshot

99285

Already fully supported: a high-complexity problem and high risk from the admission decision.

Safety questions first, revenue last. Every question is answerable in one tap.

The gap

Documentation is written at the end of a shift, for a reader who isn't there.

You reassessed the patient four times. You talked the family through a difficult decision. You watched a borderline vital sign for an hour before you were comfortable. Then you wrote three lines, because there were four more patients waiting — and the chart went out describing a fraction of what you actually did.

Under-documented

Work that genuinely happened — critical care time, an independent EKG read, a procedure — never makes it into the note, so it was never credited.

Under-defended

The reasoning behind a discharge is obvious to you at 3am and invisible to a reviewer two years later reading it cold.

Contradicted

Dictation drops a word. A lab reads negative in one section and positive in another. Nobody catches it before the chart is signed.

How it works

Three steps, one screen, about thirty seconds.

1
Paste your note
Your MDM, or the whole chart if that's easier. More context means a more thorough review.
2
Answer a few questions
Three to five targeted questions about work you already did. Skip anything that doesn't apply — skipped items stay out.
3
Copy it back
A structured MDM built only from your note and your confirmed answers, formatted for the person who codes it.

What it looks for

Three kinds of finding, in the order that matters.

Safety questions always come first. Revenue is the last thing ChartPilot brings up, not the first — which is the correct order clinically, and the honest order commercially.

Safety check

Contradictions in the chart

A penicillin allergy and a penicillin-class antibiotic. A troponin recorded negative and described as positive. The left knee documented, the right knee splinted. Asked as a question, never asserted as an error.

Chart integrity

Reasoning that isn't on the page

The risk stratification behind a discharge. The specificity that makes a diagnosis codable. Not because the care was wrong — because the note doesn't yet show why it was right.

Documentation credit

Work already performed

Critical care time. An independent EKG interpretation. A procedure whose details determine its code. Real services, delivered and undocumented — never a suggestion to bill for something that didn't happen.

The commitment

If it happened, document it. If it didn't, don't. If it's unclear, ask.

Every sentence ChartPilot writes traces back to your original note or to an answer you gave it. Say no to a question and it disappears without a trace. Paste three words and you get three words back — not a paragraph of plausible-sounding boilerplate.

Grounded in your words
No clinical fact, diagnosis, or specificity qualifier is added unless it's in the note or you confirmed it.
You confirm, then it writes
ChartPilot asks; it never fills a gap on your behalf. Declined items are excluded from the output entirely.
Level is never inflated
It won't manufacture a path to a higher E/M level, and it won't credit time or a service that doesn't meet the threshold for it.

Why not just an LLM

Two engines, because one isn't trustworthy enough.

A deterministic rules engine

Procedure and time-based checks that must fire the same way every time — critical care thresholds, EKG interpretation completeness, sedation time, post-procedure checks. These are scoped to the relevant section of the note, so a heart rate in the vitals can't be mistaken for one in an EKG read.

A clinical reasoning layer

Graded against the 2023 AMA MDM guidelines, with explicit guardrails built from real failure cases: don't bill a radiologist's read twice, don't call routine protocolized care critical care, don't ask a physician to re-justify something the note already explains.

The two engines pass context to each other, so neither re-asks what the other has already settled. That accumulated set of guardrails — every one of them earned from a case where a naive model got it wrong — is the part that can't be reproduced in a weekend.

For groups and health systems

Built to sit inside a physician's workflow, not beside it.

ChartPilot is in alpha with emergency physicians today. The roadmap from here is group-level documentation analytics, per-physician trends, SSO and role-based access, and EHR integration — the layer that turns individual chart review into a measurable program.