Referral letters, discharge summaries, medical certificates, medical information provision documents—clinical settings involve many documents that take time to create. If these medical documents can be drafted by AI, the burden on physicians is greatly reduced. This article explains how far generative AI can create medical documents, along with the mechanism, accuracy, and precautions at the time of adoption.
Medical Document Creation Is Squeezing Physicians
In addition to clinical care itself, document work is what consumes physicians' time. Take a single referral letter: reviewing the course, organizing findings, and writing the request without excess or omission—because this series of tasks is done between or after consultations, the burden accumulates. This is even more true for discharge summaries and various medical certificates.
Medical documents mainly involve the task of "reorganizing the information written in the chart into a different format." This reorganization is precisely the area where generative AI excels most.
Examples of Medical Documents Generative AI Can Create
Current generative AI can be used to draft documents such as the following:
- Referral letters (medical information provision documents): Formatting the course, findings, test results, and request into a standard text
- Discharge summaries: Summarizing the inpatient course and organizing it chronologically
- Medical certificates and opinions: Creating a draft with the necessary fields filled in based on chart information
- Patient explanation documents: Rephrasing the treatment approach into plain language
- Replies and response letters: Creating progress reports back to the referring institution
What they all have in common is that the workflow changes from "writing from scratch" to "the physician reviewing and revising a draft prepared by the AI."
How Are the Documents Generated?
The basic mechanism of medical document AI is to take the clinical information accumulated in the chart as input and generate text that follows the target document format.
With an AI integrated with the EMR, drafts can be created by automatically referencing the patient's chart information, so there is no need to enter information manually. It is also possible to connect documentation and document creation seamlessly—for example, a chart generated from consultation audio becomes the very material for document generation.
On the other hand, when using general-purpose generative AI, you must provide only anonymized information, on the premise that information that can identify a patient is not entered.
How Far Can the Accuracy Be Trusted?
The drafting accuracy of generative AI improves year by year, but it is appropriate to regard it not as "a finished product that can be submitted as-is" but as "a draft premised on review and revision."
The points to be especially careful about are as follows:
- Hallucination: The AI may plausibly fill in content that is not in the chart.
- Errors in figures and drug names: Always cross-check dosages and lab values against the original.
- Adjusting nuance: The relationship with the referral destination and the tone of the request should be finalized by the physician.
In other words, the AI quickly prepares "80% of the draft," and the physician concentrates on "the remaining 20% of review and finishing"—this division of roles is realistic.
Precautions When Using Medical Document AI
- Handling of personal information: When handling patient information, use a system that gives consideration to the secure management of medical information. Do not enter information that can identify a patient into general-purpose AI.
- The final check is done by the physician: The physician is responsible for the content of the document and should not leave it entirely to the AI.
- Consistency of templates and writing style: Whether the writing style of each clinic or physician can be maintained also affects practicality.
Seamless Document Work with an AI-Native EMR
To maximize the streamlining of medical documents, the key is that the EMR and the document generation AI are connected.
Pottech's "AI Karte" is an AI-native EMR in which the AI drafts medical documents such as referral letters, medical certificates, and consent forms based on chart information. It can generate them while preserving the clinic's own templates and writing style, and combined with automatic chart generation from consultation audio, it can streamline the entire flow from "recording" to "turning into a document." Its strength is that you can leverage daily clinical data directly, without spending effort on anonymizing personal information.
Conclusion
Generative AI is transforming the creation of medical documents from "the job of writing from scratch" to "the job of reviewing and revising." By understanding the limits of accuracy and the precautions, and by utilizing medical-specialized AI integrated with the EMR, you can significantly reduce the time spent on document work.
Through providing AI Karte, Pottech aims to be the ideal business partner for clinics—improving the working environment for physicians, nurses, and medical clerical staff, and supporting clinics in fully realizing what they want to achieve.
For more details, please feel free to contact us.