One visit, walked through.
An example: the 2:00 internal-medicine follow-up. Heart failure, CKD, diabetes, and a new complaint of fatigue, in a twenty-minute slot.
Scribe opens the encounter already knowing the chart: which conditions are longstanding, what the last visit planned, what’s changed since. As the conversation runs, the interval history lands under HPI, the medication reconciliation is captured as discussed, and the fatigue gets its own thread, documented as new, with the workup reasoning attached.
The assessment and plan come out per problem, the way internal medicine thinks: each chronic condition with its status and plan, the new complaint with its differential and next steps. Coder attaches the specificity the documentation supports while the assessment is still on the screen.
After the visit, the story continues where internal medicine actually lives, the inbox. The fatigue workup results arrive over the next week, grouped and drafted for one decision instead of five interruptions.
The longest problem lists in medicine deserve the least manual charting. Continuity, without the cost.