Complete the full medical H&P without starting from a blank page.

Move through Chief Complaint, a repeatable multi-problem HPI, ROS, past medical and surgical or procedure history, hospital and ER history, medications, allergies and intolerances, family and social history, and functional, safety, or social needs when relevant.

Return to active problems without rebuilding the whole encounter. Update the HPI by problem, review relevant findings, document decisions, and keep each assessment connected to its own plan and follow-up.

Select Negative, Positive, or Not assessed for each system and add clinical detail in the write-in areas the workflow provides. Nothing is silently marked normal, and the selected findings carry into the generated note.

Work through 22 exam areas using Normal, Abnormal, or Not assessed states, with dedicated write-in detail where the exam workflow provides it. Your selected states and findings carry into the note.

The generated note uses conventional headings, from Chief Complaint and HPI through histories, ROS, exam, diagnostics and records reviewed, assessment and differential, and plan by problem.

Add more than one concern without flattening the visit into a single narrative. Each problem can carry its own history, assessment, orders, medication decisions, education, shared decisions, follow-up, and precautions.

Begin with complaint-focused history, review, and exam sections, then show all systems whenever the visit calls for a complete view.

Optional prompts explain what to ask, why it matters, and what may still need clarification. Leave guidance off when you want a faster, clinician-led workflow.

Based on what you documented, the app may surface possible considerations, missing information, rule-outs, next questions, and safety prompts. It does not diagnose. You decide what applies.

Review how the documented complexity relates to the level of service you are considering and where the note may need clarification. The software does not determine billability. You choose and verify every code.

Check whether core documentation elements are present with clear statuses: Needs attention, Review recommended, or Core elements documented. It does not determine billability.

Review the same encounter as a full narrative or a focused summary. You confirm the final documentation, diagnoses, and codes before anything enters the record.