AI Medical Charting Best Practices

LJ Acallar

October 30, 2025•13 min read

What is AI Medical Charting?

AI medical charting is the use of artificial intelligence to automate the end-to-end process of clinical documentation to help clinicians reclaim administrative hours back to patient care.

The use of AI in medical charting has largely contributed to reducing clinician stress and improving patient outcomes, often resulting in a productivity surge among GPs. Charting's growing complexities in various care settings also necessitate clinicians' complete focus on patients who need the highest level of care.

In this article, we will evaluate the need for AI in medical charting workflows and discuss how clinicians receive and implement tools like Heidi, the AI assistant helping humans practice and receive care of top-notch quality.

An infographic titled 'AI Medical Charting: Heidi' details collaboration features with user roles and lists four safety certifications: ISO:27001, AICPA SOC, GDPR, and ISO:9001.

The Value of AI for Medical Charting

The significance of artificial intelligence in medical charting extends beyond nursing, as it benefits various healthcare workflows. AI has become an indispensable part of modern clinical practices, where the need to see patients amidst a hectic setting with a high patient throughput is crucial. The plethora of use cases where AI can be applied directly benefits care providers, but by extension, patients are also impacted with better care quality.

This quality of care is preserved even during handoffs, where interdisciplinary care teams can communicate more seamlessly with each other.

Medication errors, while preventable, are largely attributed to clinician fatigue. This phenomenon can lead to further complications of patient care, particularly when patients switch insurance providers. Although a widespread issue, clinician burnout is preventable through the implementation of tools that automate routine daily tasks.

To support the efforts of the World Health Organization (WHO) in helping clinicians improve from the prescription to the monitoring and usage of medication, Heidi provides an AI care partner that streamlines end-to-end documentation.

There are several ways to gauge the value of AI-assisted medical charting. Let’s take a look at Heidi AI and how it impacts clinicians globally in over 200 specialties.

Assessing the Real-World Impact of Electronic Medical Charting

The real-world value of AI-embedded medical charting systems can be measured by customer satisfaction and adoption rates. In the KLAS study for Heidi, 100% of participants reported achieving their intended outcomes. This includes reduced documentation time and enhanced clinical accuracy, with most seeing results immediately or within six months.

Heidi also received an overall performance score of 93.4 out of 100 in KLAS’s 2025 software performance assessment, outperforming the Best in KLAS market average for ambient speech tools, which was 93.3. Heidi’s performance score of 93.4 was based on feedback from 16 unique organizations, surpassing the KLAS threshold for a fully rated dataset.

Heidi helps you avoid preventable harm in care, and only by embedding it in your workflow shall you truly maximize its clinical potential. The video below shows how Heidi’s AI streamlines medical charting without slowing down care.

How AI Medical Charting Transforms Record-Keeping

To understand how AI medical charting transforms record-keeping, we provided a brief rationale illustrating the dire need for a documentation assistant, followed by actual clinician experiences showing the breadth of AI medical charting solutions.

The Burden of Traditional Note-Taking in Healthcare

In the healthcare sector, the traditional approach to note-taking has long been a significant source of burden for clinicians like you. This task, often seen as a necessary but cumbersome part of the job, has several inherent challenges:

Time Consumption: Traditional note-taking is a time-intensive process. Clinicians often spend hours documenting patient encounters, time that could otherwise be spent in direct patient care or other critical tasks. The manual process of writing or typing notes, organizing them into coherent records, and ensuring their accuracy consumes a substantial portion of your workday.
Quality of Care Impact: The diversion of your attention from patient interaction to documentation can impact the quality of care. When clinicians are preoccupied with note-taking, their ability to engage fully with patients, observe subtle symptoms, and provide personalized care can be diminished.
Risk of Burnout: The added stress and workload from extensive note-taking contribute to clinician burnout. This aspect of the job can be particularly draining, leading to decreased job satisfaction and, potentially, a decline in the overall quality of healthcare delivery.

The evolution towards AI-enabled medical charting platforms promises to address these challenges. By automating the documentation process and providing intelligent, context-aware transcriptions, AI medical charting tools like Heidi offer a reliable and compliant care partner. It not only reduces clinicians’ mental load but also enhances the overall quality and accuracy of medical records.

When asked what life would look like without Heidi, Liah McCann of Primary Health shared, “We would all quit.” This is a testament to how transformative Heidi AI is in the lives of clinicians in need of more efficient charting workflows.

Heidi also goes beyond mere time-saving by providing clinicians with complete documentation that ensures peace of mind. This allows them to make quicker and clearer decisions, ultimately guaranteeing high-quality patient care.

For example, Pediatrician Dr. Keyvan Hadad shares, “...a lot of GPs have written back to me, and they say how much they enjoy how [my letter] included my thought process.” Working with Heidi sped up his process for sending letters to GPs, which formerly took up to six long weeks.

On another note, Dr. Sanjay Mehta, a Pediatric Emergency Physician, describes how Heidi has reshaped his clinical rhythm. Before Heidi, late nights were spent routinely finishing charts, but now, his custom pediatric templates keep documentation precise yet natural.

For veterinary surgeon Dr. Charles Kuntz, using Heidi saves him at least an hour a day. It helped him set a new standard for precision in veterinary documentation.

With Heidi, clinicians stay present with kids and families while remaining thorough. The patient conversation drives the production of high-fidelity notes, resulting in more energy for care and an end to leaving the clinic with a stack of unfinished charts.

Basic Practices in AI Medical Charting

Care settings may vary in capacity and scope, but basic practices in using AI for medical charting are always aligned to continuously optimize the way care is delivered. Let’s take Heidi’s AI capabilities to demonstrate.

From Patient Intake to Document Creation

Procedural steps are easier for any practice with Heidi. For instance, when you use Heidi’s AI-powered medical charting platform, it can start taking in medical dialogue at the beginning of your patient encounter. Silently working in the background, Heidi automatically organizes clinical information into notes, like SOAP, DAP, or BIRP, among others.

After the encounter, your assessment of the patient, interpretation of the findings, diagnoses, what the patient reported, and the existing care plans to be modified are now in a single workspace. With your evaluation, intervention details for referral plans can be repurposed to generate documents like letters, complete with the name and affiliation of your office. There is nothing you cannot control or supervise in the final note output.

Streamlined Care Collaboration

Hospitals and health systems embed Heidi into their work environment, and unsurprisingly, the results bring streamlined patient records. Within Heidi, you can personalize the documentation templates to enhance billing efficiency for insurance companies. Its system flags potential misdiagnoses when medical charts are edited, even at a later stage.

Heidi assists you in completing comprehensive documentation in the following ways, which leads to increased patient throughput and reduced wait times.

No more documentation delays: Heidi handles your note-taking so you can talk with your patients, and so that illegibility of notes is already eliminated (e.g. writing “hyper” vs. “hypo”) and notes can be pushed into the EMR within the day.
Oversee final note output: All you’re left to do is a quick review of necessary medical details such as required dosages, medical codes, and timestamps. The need to check for typos and the tendency to enter data into the wrong patient chart are minimized.
See everything in a shareable workspace: Multiple modifications of the patient chart, such as omission of medications, are auto-updated every time a care provider provides new context. You retain ultimate control over access, so you can share it with other clinicians or care teams.

The lack of technical training among GPs and nurses to use AI in medical charting is not a hindrance, thanks to Heidi’s user-friendly interface, which eliminates the need for complicated onboarding. Right away, Heidi can be used so that thorough documentation can be pushed into systems and so clinicians can actually return to interacting with patients.

Spend Less Time Charting and More Time with Patients Using Heidi

No matter your location and practice, Heidi is built for your reality in modern care. Heidi empowers you to prioritize patient needs and supports you every step of the way. It records, writes, and structures clinical notes automatically so you can focus fully on your patients.

Join thousands of clinicians using Heidi for various use cases to reclaim time:

Generating notes tailored to your preferred structure, such as SOAP, DART, or a custom template
Seamlessly formatting and transferring notes into medical records software (such as Shexie, Cliniko, or PracticeQ)
Translating treatment plans and notes into your patient’s preferred language

Heidi securely supports more than 1.8 million consults every week while meeting strict global privacy standards. It is ISO27001-certified and fully compliant with HIPAA, GDPR, NHS, APPs, and others, ensuring all data remains local to each region. No recordings are kept, and clinicians retain complete control.

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Frequently Asked Questions about AI Medical Charting

How can AI help with medical charting?

AI helps with medical charting in ways that reduce the time spent on documentation and save clinicians the mental capacity to focus on patients. It does so by automating the note generation process to ensure accuracy and consistency, and at the same time, reducing error rates. The way it structures data automatically enhances note consistency, making them audit-ready and fully compliant.

Can I use AI to summarize medical records?

Yes. Summarizing medical charts is a known major contribution of AI in helping healthcare professionals. This way, clinicians can have a head start at understanding the patient’s record history. For instance, when Heidi handles baseline documentation, it leaves clinicians to polish, and they can Ask Heidi to tailor documents based on the context of the note.

How can medical charting AI boost productivity in varied practices?

Reducing documentation burden imposes efficiency and productivity gains across generalist and specialist settings. Individual practitioners and care teams can focus on making more careful care decisions by ensuring that records resonate with clinical accuracy as well. For example, Heidi adapts to clinicians of all types, and it has proven successful in metrics such as time saved per provider, patient throughput, and work-life balance.

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