AI Clinical Documentation Review

Industry: Healthcare, general practice and clinical governance
Organisation: Australian health technology startup founded by a practising GP
Solution type: AI SaaS platform with admin portal
Core technology: Azure OpenAI, Azure AI Search, Azure AI Speech, .NET, Angular
Engagement: Architecture, build and ongoing support

Headline resultLive in early access, giving GPs a structured review of notes before they sign

Overview

AI scribes help doctors write clinical notes faster, but they do not check whether those notes are complete or defensible. Using our AI software development services, we built an AI documentation review platform that sits alongside any scribe and reviews each note before the GP signs it, prompting them about missing reasoning, safety netting or consent discussions.

The Business Problem

The treating doctor remains responsible for every clinical record, even when an AI scribe drafted it. Gaps in documentation are a common factor in complaints and disciplinary matters, yet busy GPs have no practical way to check each note against regulatory expectations.

Unverified AI notesAI scribes produce notes quickly but do not verify them
Missing safety elementsCritical elements such as safety netting and consent are easily omitted
Clinician riskClinicians carry the legal and professional risk
Data controlPatient data and the knowledge base must remain under the client’s control

Our Solution

We built a retrieval augmented generation (RAG) pipeline using .NET microservices. A curated knowledge base of regulatory guidance and analysis of thousands of published tribunal decisions is stored and indexed with Azure Blob Storage, Azure AI Document Intelligence and Azure AI Search. For each note, relevant guidance is retrieved and passed to Azure OpenAI Service, which scores the note against a structured framework and returns plain English prompts.

Azure AI Speech converts consultation audio to text, so the platform is not tied to a single scribe product. An Angular admin portal manages tenants, account status and usage. All AI services and data run in the client’s own Azure tenant, so the client keeps full control of its intellectual property and data.

GP finishes a consultation note
Platform reviews the note
Checked against curated guidance
Prompts shown before signing
Doctor signs with confidence

AI clinical documentation review tool for GP practices

Key Features

Works alongside any AI scribe
Speech to text consultation capture
Structured, multi factor documentation scoring
Plain English improvement prompts, not just a score
SOAP note generation with a change history ledger
Full audit trail for every review
Multitenant admin portal with trial, paid and suspended account states
Usage tracking per practice and clinician

Outcomes

Platform live in controlled early access with Australian GPs
GPs receive actionable feedback before signing notes
Microservices architecture allows expansion into aged care, allied health and other jurisdictions
The client owns and controls its IP and can extend the platform independently

Technology Stack

Frontend4 technologies

Angular

HTML

CSS

JavaScript

Backend5 technologies

.NET

REST APIs

Entity Framework

Microservices

Database1 technology

SQL Server

AI4 technologies

Azure OpenAI Service

Azure AI Search

Azure AI Document Intelligence

Azure AI Speech

Cloud and DevOps4 technologies

Azure Web Apps

Azure API Management

Azure Blob Storage

Azure DevOps

Who This Solution Suits

This approach suits health technology startups, medical defence and governance organisations, and healthcare providers wanting AI that improves documentation quality while keeping sensitive data in their own cloud environment.