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Illustration of one visit on a single card. Before the visit, AmbiScript summarizes a 58-year-old man with hypertension, prediabetes, and hyperlipidemia: his last visit on June 16, 2026, and three open care gaps: an overdue A1c, a urine albumin test not on file, and colorectal screening due. It shows rising blood pressure and declining kidney function, a risk adjustment factor of 0.412 this year against 0.539 last year because chronic kidney disease stage 3a has not been documented yet, and predictive risk signals. During the visit, it extracts findings as they are spoken and writes the note. After the visit, it prepares ICD-10, CPT, and E/M coding suggestions with their sources and the RAF impact, orders, a referral, and the next visit date. The after-visit summary explains the medication change, how to check blood pressure at home, how to protect the kidneys, how to eat less salt, and when to call the office or 911. The clinician signs and sends it.

Pre-visit summary

NotesLabsVitalsMedicationsClaims1,284 data points

58-year-old man, established patient since 2019 Follow-up today, Sep 28, 2026 at 9:40 AM. Last visit Jun 16, 2026, 14 weeks ago.

Problems and medicationsEssential hypertension, prediabetes, hyperlipidemia. Lisinopril 10 mg, atorvastatin 20 mg daily.

Trends Blood pressure 138/86 → 152/94Rising eGFR 63 → 58 → 54, under 60 for more than 3 monthsDeclining

Risk Possible CKD stage 3a, not documented this yearReview Kidney disease progressionElevated

Open care gaps

Hemoglobin A1cJul 22, 2025Overdue

Urine albumin (UACR)Not on fileRecommended

Colorectal cancer screeningNever completedDue

Suggested agendaIntensify blood pressure treatment. Confirm whether CKD stage 3a applies. Order A1c and UACR. Refer for colorectal screening.

Visit in progressCapturing

ClinicianYour blood pressure is still high, and your kidney numbers are lower again.

PatientI still haven't done the colonoscopy either.

ClinicianLet's increase lisinopril to 20 and check your A1c today.

HCCKidney decline discussed. Confirm whether CKD stage 3a applies before documenting.

Extracted

FindingBP above goal FindingeGFR under 60 Care gapColonoscopy MedicationLisinopril 20 mg Care gapA1c

Structured noteWriting

Prepared for review

Coding suggestions ICD-10  CPT  E/M Established patient, moderate MDM Simulated RAF impact

Source for N18.31Your blood pressure is still high, and your kidney numbers are lower again.Supported by eGFR 63, 58, and 54 over 14 months. Suggested only after the clinician confirms the diagnosis.

RAF impact, simulated example Demographics0.412 CKD stage 3a, HCC 329+0.127 RAF with this visit0.539Simulated. Actual values depend on the model year, patient factors, and coding review.

OrdersLisinopril 20 mg daily; hemoglobin A1c; urine albumin-to-creatinine ratio; basic metabolic panelReview

ReferralGastroenterology for screening colonoscopy, reasoning attachedReview

Care gapsA1c and UACR ordered; colorectal screening referred. Completion pending.3 addressed

Follow-up recommendedIn 4 weeks: blood pressure and kidney function after the dose changeRecommended

After-visit summaryENESVI中文AR

What we changed todayTake lisinopril 20 mg once a day.Your dose went up from 10 mg. Take it at the same time each day.

Check your blood pressure at homeSit quietly for 5 minutes, then check it twice each morning. Write down both numbers and bring them to your next visit. Your goal is below 130/80.

Protect your kidneysYour kidneys are working a little less well than normal. Avoid ibuprofen and naproxen. Acetaminophen is safer for pain.

Eat less saltAim for less than 2,000 mg of sodium a day. Canned soup, deli meat, and restaurant meals are the biggest sources.

After-visit summaryNext steps

Your next steps

• Blood tests today: A1c, urine protein, and kidney function. We will message you the results.
• The GI office will call you within 2 weeks to schedule your colonoscopy.
• Follow-up visit in about 4 weeks, to check your blood pressure and kidneys.

Call 911 if you haveChest pain or pressure, trouble breathing, swelling of your lips, tongue, or throat, or sudden weakness or trouble speaking.

Call our office if you haveDizziness when you stand up, a dry cough that does not go away, new swelling in your legs, or home readings above 180/110 twice.

Reviewed by the clinicianSign and send

Signed and sent

6items prepared and signed

3care gaps addressed, completion pending

0.412 → 0.539Simulated RAF, if CKD 3a is confirmed

4 weeksfollow-up recommended

Illustration of one issue on a single card with a camera that zooms out. At the Unit 4 huddle, staff raise a transport delay, and transport data confirms it. The unit briefing shows staffing and patient flow below target in red and safety and equipment above target in green. The camera zooms out from Unit 4 to the whole facility, where Units 4 and 6 are below target in red and an owner is assigned, then out again to the region, where only one facility is affected. An action record shows the owner, the intervention, the outcome measure, and the verification step. The action is completed; discharges before noon rise above target for two days, and the outcome stays under review. The execution score reaches 86 percent. Finally, the executive briefing summarizes the whole health system today: safety, staffing, and equipment above target, patient flow below target but recovering, what is working, one decision for leadership, and a system execution score of 84 percent.