Discharge Summary and Medical Record Structuring

• Medical Superintendent
• Head of Medical Records (MRD)
• Consultants and resident doctors
• Chief Information Officer

A discharge summary should bring together the admission diagnosis, course in hospital, procedures, key investigations, medicines on discharge and follow-up advice. In practice a resident assembles it from handwritten progress notes, OT notes, the drug chart and lab printouts, often late in the day while the patient waits to leave. Old discharge summaries and referral letters that patients bring in stay as scanned images nobody can search.

We build a record structuring service that reads the inpatient file and incoming past records. For discharge, it assembles a draft summary in your hospital's template: diagnosis, history, course in hospital, procedures with dates, key investigation results, condition at discharge, medicines on discharge checked against the final drug chart, and follow-up advice as the team wrote it. Each sentence links to the note or report it came from. The treating doctor edits and signs, and nothing is released unsigned. For past records, it extracts diagnoses, procedures, medicines and allergies into structured fields and suggests ICD-10 codes for the medical records team to confirm.

• Reads typed and handwritten progress notes, OT notes, drug charts and investigation reports
• Drafts the discharge summary in your template with a source link on every sentence
• Compares medicines on discharge with the final drug chart and flags differences for the doctor
• Extracts diagnoses, procedures, medicines and allergies from past discharge summaries and referral letters
• Suggests ICD-10 codes for medical records coders to confirm or change
• Exports structured data to your HIS, and to FHIR-based formats where ABDM integration is in place

1. 01Collect the inpatient fileWhen discharge is planned, notes, OT records, the drug chart and reports are pulled from the HIS or scanned from the paper file.
2. 02Extract and organiseEach document is classified and its clinical facts extracted with dates and source references.
3. 03Draft the summaryA draft is assembled in the hospital template using only facts found in the record.
4. 04Check consistencyMedicines, procedure dates and diagnoses are cross-checked across documents, and mismatches and gaps are highlighted.
5. 05Doctor review and sign-offThe treating doctor edits the draft, resolves each flag and signs the summary in the HIS.
6. 06Code and storeCoders confirm suggested ICD-10 codes, and the structured record is saved for future visits.

1. Ingestion
   • HIS or EMR connector
   • Scanner and paper file upload
   • Patient episode grouping by UHID and IP number
2. Document understanding
   • Handwriting-capable OCR
   • Clinical document classifier
   • LLM fact extractor with source spans
3. Drafting and checks
   • Template-based summary composer
   • Medication cross-check against drug chart
   • ICD-10 code suggester
4. Clinical review
   • Doctor review and e-sign screen
   • MRD coding queue
5. Storage and audit
   • HIS write-back and FHIR export
   • Audit log of drafts, edits and signatures

The treating doctor reviews, edits and signs every discharge summary; no draft reaches the patient, insurer or record unsigned. Medical records coders confirm every suggested code.

• Hospital information system or EMR (HL7, FHIR, API or database views)
• Document scanners and DMS
• ABDM-integrated health record systems where applicable
• Insurance desk and billing module
• Single sign-on for clinician access

• Drafts use only facts present in the record, with no inferred diagnoses or advice
• Every sentence carries a link to its source document and page
• Unsigned drafts are watermarked and cannot be printed or shared
• Role-based access aligned with HIS permissions, with patient data masked in logs
• Regular MRD audit of signed summaries against source records

• Health data handled with consent, purpose limitation and security safeguards under the DPDP Act 2023.
• Designed as a documentation aid; clinical content remains the responsibility of the treating doctor.
• For US deployments, built to operate under HIPAA safeguards and a business associate agreement.

• Healthcare & Hospitals

  Clinical Documentation from Doctor Dictation

  Doctors dictate in English or Hinglish after a consultation, round or procedure, and the system drafts a structured note or prescription in your EMR template for the doctor to check and sign.

• Healthcare & Hospitals

  Lab Report Digitisation and Trend Extraction

  Turn external lab reports, PDFs and phone photos into structured results mapped to standard test codes, and show trends over time to the treating doctor with every value linked to its source.

• Healthcare & Hospitals

  Insurance Pre-Auth and Claim File Preparation for Hospitals

  Assemble cashless pre-auth, enhancement and final claim files for TPAs, insurers and government schemes, and check each against the payer's checklist before submission.

• Insurance

  Health Claim Document Extraction

  Turn hospital bills, discharge summaries and investigation reports into structured, checked claim data, with uncertain fields routed to an assessor instead of guessed.