Overall Quality Score
87/100
Completeness
92/100
Accuracy
89/100
Compliance
81/100
AI analysis identified 15 consultation notes missing complete assessment sections. This affects 8% of all consultations in the last 30 days.
Pattern detected primarily in cardiology consultations by Dr. Wilson and Dr. Patel. The "Assessment" heading exists but often contains only 1-2 sentences without differential diagnoses or risk stratification.
AI detected inconsistent medication documentation patterns across 32 clinical notes. Dosage information is missing in 24% of medication entries.
Common pattern of omitting units of measurement (mg, mcg) and frequency (daily, BID). Structured medication fields are properly completed but narrative text in the Plan sections contain these inconsistencies.
67% of initial evaluation notes lack comprehensive documentation of social determinants of health. This affects reimbursement and quality reporting.
Most notes mention employment status but omit housing security, food access, transportation challenges, and social support. Medicare Annual Wellness visits are most affected, potentially impacting risk adjustment factors.
CMS E/M Documentation
CompliantAI-analyzed 1,245 encounter notes against 2024 E/M guidelines
HIPAA Privacy Requirements
CompliantNo PHI detected in non-compliant contexts
Joint Commission Requirements
CompliantPain assessment documentation meets standards
Medical Necessity Documentation
At Risk17 radiology orders missing sufficient justification
AI continuously monitors documentation against the latest regulatory requirements. Last regulatory update: 04/01/2025
Detected regulation change: CMS 2025 Quality Payment Program updated measure specifications
| Provider | Overall Score | Completeness | Accuracy | Compliance | Trend | Action |
|---|---|---|---|---|---|---|
|
Dr. Sarah Chen
Cardiology
|
94/100
Excellent
|
96%
|
95%
|
92%
|
↑ 4% | |
|
Dr. Michael Wilson
Cardiology
|
73/100
Needs Improvement
|
65%
|
78%
|
76%
|
↓ 2% | |
|
Dr. James Patel
Internal Medicine
|
88/100
Good
|
90%
|
87%
|
88%
|
↑ 6% |