Documentation Types Rubric supports evaluation of various clinical documentation formats:
SOAP Notes The standard format for outpatient encounters:
{ "soap_note" : { "subjective" : "..." , # Patient-reported symptoms, history "objective" : "..." , # Exam findings, vitals, labs "assessment" : "..." , # Clinical impression, diagnoses "plan" : "..." # Treatment, follow-up } }
H&P (History & Physical) Comprehensive documentation for admissions:
{ "hp_note" : { "chief_complaint" : "..." , "hpi" : "..." , "past_medical_history" : "..." , "medications" : [ ... ], "allergies" : [ ... ], "family_history" : "..." , "social_history" : "..." , "review_of_systems" : { ... }, "physical_exam" : { ... }, "assessment_and_plan" : "..." } }
Procedure Notes Documentation of procedures performed:
{ "procedure_note" : { "procedure" : "..." , "indication" : "..." , "consent" : "..." , "technique" : "..." , "findings" : "..." , "specimens" : [ ... ], "complications" : "..." , "disposition" : "..." } }
Clinical Note Evaluators Completeness Evaluator Checks for required documentation elements:
{ "type" : "note_completeness" , "config" : { "note_type" : "soap" , "required_sections" : [ "subjective" , "objective" , "assessment" , "plan" ], "required_elements" : { "subjective" : [ "chief_complaint" , "hpi" , "ros" ], "objective" : [ "vitals" , "exam" ], "assessment" : [ "diagnoses" ], "plan" : [ "treatment" , "follow_up" ] }, "specialty_requirements" : "internal_medicine" } }
Accuracy Evaluator Validates factual correctness against source material:
{ "type" : "note_accuracy" , "config" : { "source_types" : [ "transcript" , "prior_notes" , "labs" ], "check_medications" : True , "check_allergies" : True , "check_diagnoses" : True , "check_vitals" : True , "strict_mode" : False # Allow reasonable inference } }
Hallucination Detection Identifies claims not supported by source:
{ "type" : "hallucination_detection" , "config" : { "sensitivity" : "high" , # low, medium, high "categories" : [ "unsupported_symptom" , "fabricated_history" , "incorrect_medication" , "wrong_patient_data" , "invented_lab_value" ] } }
Medical Coding Accuracy Evaluates ICD-10 and CPT code suggestions:
{ "type" : "coding_accuracy" , "config" : { "code_types" : [ "icd10" , "cpt" ], "check_specificity" : True , # e.g., E11.65 vs E11.9 "check_medical_necessity" : True , "check_documentation_support" : True } }
Quality Metrics SOAP Note Scoring Component Weight Criteria Subjective 25% Complete HPI, relevant ROS, accurate history Objective 25% Pertinent exam, accurate vitals/labs Assessment 25% Appropriate diagnoses, clinical reasoning Plan 25% Complete, addresses each diagnosis, follow-up
Documentation Quality Score Composite metric considering:
Quality Score = (Completeness × 0.3) + (Accuracy × 0.4) + (Coding × 0.2) + (Readability × 0.1)
From Ambient Transcription client.notes.log( project = "ambient-scribe" , # Raw audio/transcript from encounter input_transcript = [ { "speaker" : "provider" , "text" : "What brings you in today?" }, { "speaker" : "patient" , "text" : "I've had this cough for about two weeks." }, # ... ], # Optional: structured EHR data available during generation context = { "prior_notes" : [ ... ], "medications" : [ ... ], "allergies" : [ ... ], "labs" : [ ... ] }, # AI-generated output output = { "soap_note" : { ... }, "icd_codes" : [ ... ], "cpt_codes" : [ ... ] } )
From Prior Note Summarization client.notes.log( project = "chart-summarizer" , # Source documents input_notes = [ { "date" : "2024-01-15" , "type" : "progress_note" , "text" : "..." }, { "date" : "2024-01-10" , "type" : "lab_result" , "text" : "..." }, # ... ], # Generated summary output = { "summary" : "..." , "problem_list" : [ ... ], "active_medications" : [ ... ], "recent_labs" : { ... } } )
Copy-Forward Detection Identify inappropriate duplication from prior notes:
{ "type" : "copy_forward_detection" , "config" : { "similarity_threshold" : 0.85 , "check_dynamic_fields" : True , # Vitals, labs should change "exempt_fields" : [ "allergies" , "past_medical_history" ], "flag_unchanged_exam" : True } }
Copy-forward of dynamic data (vitals, exam findings) without verification is a significant compliance and patient safety risk.
Specialty-Specific Requirements Rubric supports documentation requirements by specialty:
Specialty Required Elements Primary Care Preventive care reminders, chronic condition management Cardiology Risk factor assessment, anticoagulation documentation Psychiatry Mental status exam, safety assessment, substance use Surgery Informed consent, procedure details, complication documentation
{ "type" : "specialty_requirements" , "config" : { "specialty" : "psychiatry" , "required_elements" : [ "mental_status_exam" , "suicide_risk_assessment" , "substance_use_screen" , "medication_reconciliation" ] } }
Next Steps
Notes Overview Documentation evaluation basics
Clinician Review Human review for flagged notes
