AI clinical documentation

AI clinical documentation

Mediyn’s AI documentation tools handle the full clinical documentation lifecycle — from capturing a session recording or transcript through AI-generated drafts, therapist review, and final approval. The features described below are available on the Mediyn web app; select capabilities are also available on iOS.

Session Capture and Submission

• Therapists can create and submit sessions directly from the Mediyn web app without an iOS device.
• Supported upload formats are MP3, M4A, WAV, WebM, MP4, FLAC, and OGG, up to 500 MB. Files larger than 500 MB or in unsupported formats are rejected with a clear error message.
• Sessions can also be submitted by pasting session notes as text; Mediyn generates clinical artifacts from either input method.
• When uploading a session recording, the patient dropdown shows only the patients assigned to your account, preventing accidental selection of another therapist’s patient.
• A live progress view shows each processing step as it completes.
• Mediyn prevents a patient from having more than one active session open at the same time. If you attempt to start a new session while a prior one is still in progress, the request is declined and a reference to the existing active session is shown. Once the prior session is completed or closed, a new session can be started.
• When submitting a session fails — for example, because a conflicting session is already in progress — the error message appears directly above the Submit button and as a notification. After resolving the issue, you can resubmit immediately without reloading the page.
• Session workflows follow a defined sequence of stages from scheduling through review and approval. Attempts to skip required stages are rejected with a clear message indicating the next valid stage.

AI-Generated Clinical Documentation

• After uploading a recording or transcript, Mediyn automatically generates a full transcription, a structured session summary, and actionable key insights. These drafts appear in your review queue ready for editing and sign-off.
• Session summaries and key insights reflect your patients’ clinical history — including recent standardised assessment scores and completed worksheet themes — even when those details were not mentioned aloud during the session. The AI uses this context to surface clinically relevant patterns, flag score-based concerns, and connect session content to ongoing therapeutic work. No changes to your existing workflow are required.
• Mediyn supports four structured clinical note formats: SOAP, BIRP, DAP, and GIRP. Therapists can set their preferred format in their profile and optionally override it for individual sessions. AI-generated notes are returned with clearly labelled sections matching the chosen format.
• Assessment recommendations include a brief explanation of why the AI suggested each instrument.
• Sessions created by uploading a recorded audio file automatically move to the review stage once Mediyn finishes processing. Clinical notes, summaries, and insights are immediately available in your review workflow without manual intervention.
• Session pages update automatically when AI processing completes — transcriptions, summaries, assessment recommendations, and insights appear without needing to reload the page.

Session Review and Approval

• The Session Review Workspace groups all next-step actions — assigning worksheets and scheduling assessments — into a single Next Steps card.
• Key patient details including insurance and current diagnoses are visible in the right panel without navigating away from the session. Diagnosis codes appear as inline pills within the Clinical Summary.
• An Approve All button lets you sign off on all AI-generated artifacts in one click.
• Before a session can be approved, Mediyn verifies that the transcription, session summary, and key insights have all been generated. If any are missing, approval is blocked and a clear message identifies which items are incomplete. This prevents incomplete invoices or superbills from being created.
• Once all three artifacts — Transcript, Summary, and Key Insights — are individually approved, the session is automatically marked as approved with no extra step required.
• After approving all session artifacts, Mediyn automatically brings you to the Assignments tab where AI-recommended assessments and worksheets are ready to assign. The Assignments tab is visible during the review process and activates as soon as all artifacts are approved.
• After a session’s clinical notes and insights have been approved, you can review them in a dedicated Completed session view. From this screen you can assign AI-recommended worksheets directly to your patient, schedule follow-up assessments, and track which items have already been sent or completed. All previously approved content remains visible in read-only format.

Edit History and Audit Trail

• Therapists can view the full edit history of clinical artifacts — including transcriptions, summaries, and key insights — directly in the Session Review Workspace.
• Each version shows what the content was, who made the change, and when it was saved.
• Previous versions of content remain accessible and recoverable from within the Session Review Workspace.
• Artifact version history is available through the Mediyn web app, which is designed for in-depth documentation workflows.

Dashboard and AI Feed

• The Mediyn dashboard shows your AI clinical pipeline at a glance — from recorded sessions through generated artifacts, completed assessments, and worksheet drafts, through to patient delivery.
• Contextual action prompts surface what needs your attention, such as unreviewed drafts or patients due for reassessment, without requiring you to check multiple pages.
• The AI Feed shows the specific worksheets generated for each session by name, along with their review status. Cards look and behave differently depending on whether a session is awaiting review, already approved, or still processing.
• The Sessions to Review section on the dashboard shows the true total number of sessions awaiting review, not just the number visible in the preview table. A View All link provides full access.
• Therapists receive a notification when a session is ready for review after AI processing completes, when worksheet recommendations have been generated, or when a session processing job fails.
• Notification alerts navigate directly to the correct session and include the patient name so you can identify which session the alert refers to at a glance.

Patient Overview and Clinical Summary

• The patient overview tab shows a focused clinical summary before each session, including recent session notes, active assessments and worksheets, and AI-generated recommendations — all in one place.
• Billing totals and package balances are visible at a glance without navigating away.
• Submitted worksheets awaiting review can be actioned directly from the overview.
• The Clinical Summary tab automatically fills in Allergies, Current Diagnoses, Past Diagnoses, and Suicidal Ideation Screening from information patients provide during their clinical intake. Medication entries display with their name visible. These sections no longer require manual re-entry after a patient completes their intake form.
• When patients submit their intake form with responses such as “None” or “N/A” for medications, allergies, or diagnoses, those fields correctly appear as empty in the Clinical History section rather than as clinical entries.

Documents and Consent Management

• When a patient signs a HIPAA, treatment, or telehealth consent in Mediyn, a copy of the signed document automatically appears in both the patient’s and the therapist’s document library. Therapists can open a document to see that it was generated from a signed consent and navigate directly to the consent record.
• Patients can download their signed consent PDFs directly from the patient portal.
• For paper or offline consents, a scanned PDF can be linked to an open consent record from the intake workflow, marking it as obtained without re-requesting a signature.
• Clinic administrators can define reusable document templates — such as intake forms and consent documents — once, and generate patient-specific copies on demand with automatic variable substitution (for example, patient name and appointment date). Generated documents appear immediately in the patient’s document library. Changes to a template after generation do not affect previously generated documents.
• You can upload existing documents — PDFs, Word files, plain text, or images — directly to a session. Mediyn processes the document and incorporates its content into clinical notes and other session artifacts. Upload progress and processing status are shown in the session detail view.
• The Documents list shows the associated patient name and session for each document. Documents not linked to a patient display an empty value rather than a placeholder.
• You can page through your document list and filter by filename, status, or date range directly from the documents view.
• A document’s name, category, description, and patient or session assignment can be edited directly from the document detail panel without deleting and re-uploading. All changes are recorded in the audit history.
• You can select multiple documents at once using checkboxes, then recategorize them, delete them in one step, or download them all as a single zip file. Bulk delete requires one confirmation regardless of how many files are selected, and zip downloads preserve original filenames.

Messaging and Quick Replies

• Quick reply suggestions always contain complete, ready-to-send text with no placeholder tokens. Crisis resource replies include verified helpline information.
• When a patient or therapist sends a message, Mediyn automatically suggests relevant actions — such as rescheduling or cancelling an upcoming session — directly in the conversation thread as one-tap buttons.
• Messages that contain crisis language are automatically flagged as urgent, and therapists are presented with immediate actions including sending crisis resources and scheduling an emergency session.
• Patients see contextual shortcuts in therapist messages, such as joining a telehealth call, opening an assigned worksheet, or viewing assessment results.

iOS App

• Therapists can review all AI-generated clinical artifacts for a session in the iOS app, make corrections before approving, and formally approve the session record with a single tap. Each artifact — transcription, clinical summary, and key insights — can be reviewed and edited independently. The session approval button remains disabled until all artifacts have been individually confirmed.
• After a session is approved, tapping any artifact opens the full content in an expanded read-only view.
• The AI Feed on the iOS Home screen shows a live view of sessions moving through the AI pipeline. Each card displays the session date, current processing state, a session summary, any risk indicators flagged by the AI, assessment and worksheet recommendations with confidence scores, and a direct link to review the full session. The Home screen displays your five most recent sessions, with a View All option to see the complete list.
• The Pending Review section on the Home screen shows all sessions ready for review, each with a Review Session Summary shortcut.
• Tapping a session in Today’s Schedule takes you straight to the Recording screen for that session. Session details such as time, duration, and session number appear directly on the Recording screen.
• When you start a session recording from Today’s Schedule, the app checks whether you are within the scheduled time window and shows a notice if you are starting early or the scheduled time has passed. You can still choose to start recording.
• You can tap any session — from your schedule, a patient’s history, or the home screen — to open a full Session Detail view and take actions such as approving, cancelling, rescheduling, or marking a no-show from one place.
• If a patient already has a session in progress when you tap Create Session, the app shows a prompt letting you continue the existing session or delete it and start a new one.
• Recording a note from the iOS app correctly attaches to any session already in progress for that patient rather than creating a duplicate.
• Your screen stays on for the entire duration of a session recording. Once you stop recording and processing completes, the device returns to its normal screen-timeout behavior.
• When assigning a patient to a recording session, the app displays your actual patient roster with name search.

Willow Assistant

• Willow can look up and cite accurate information from Mediyn’s knowledge base when answering questions about the platform. Responses to product and documentation queries are grounded in published Mediyn help content. When Willow does not find relevant documentation, it will say so rather than guessing.