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Decoda
Clinical Notes

Charting is the tax
you pay after everyone goes home.

The clinical work ended at five. The documentation is still open at seven, and the details are getting fuzzier the whole time.

4 notes open
Recalling from memory
Charting queue
6:40 PM
Sarah W.
Today 9:15
6h unsigned
Marcus T.
Today 10:40
4h unsigned
Priya N.
Yesterday
1d unsigned
Dana R.
Mon
3d unsigned
The last patient left an hour ago

Ambient scribe

The note is written by the time you stand up.

The scribe listens to the consultation and drafts into your own note template as it goes. You review and sign instead of reconstructing the visit from memory four hours later.

  • Structured into the template your practice already uses
  • Provider reviews and edits before anything is signed
  • Timestamped record of what was actually discussed
  • Feeds the same chart your billing and inventory read from
Scribe · listening
Subjective
Patient reports satisfaction with prior treatment. Interested in addressing glabellar lines.
Objective
Moderate dynamic rhytids at glabella. No asymmetry noted.
Assessment
Appropriate candidate for neuromodulator.
Plan
Botox 24u glabella. Follow-up in 2 weeks.
Drafted while the conversation happens, not after it

Every note type

Not every visit needs a full SOAP.

A follow-up touch-up and a new-patient consult produce very different documentation. Forcing both through one template is why charting feels like paperwork.

  • Ambient scribe notes for full consultations
  • Manual charting when you'd rather write it
  • Quick notes for a two-line observation
  • Document uploads for outside records and referrals
Add to chartSame record
AI Scribe note
Ambient, structured to your template
Manual chart note
When you'd rather type it yourself
Quick note
Two lines, no template, still on the record
Uploaded document
Outside records and referrals, filed
Four ways in, one chronological chart.

Closing the loop

An unsigned note is an open liability.

Sign-off workflows make the outstanding queue visible to the person who has to clear it, and to the medical director overseeing it, rather than letting it quietly age.

  • Outstanding notes visible per provider, not buried
  • Medical director oversight where sign-off is required
  • Clinical gallery keeps treatment photos on the record
  • Everything timestamped and attributable after the fact
Sign-off
Queue clear
Sarah W.
Dr. Chen
Signed 2:41 PM
Marcus T.
Dr. Chen
Signed 2:39 PM
Priya N.
Dr. Okafor
Signed 11:02 AM
Signed before anyone left the building.

Leave when the last patient does.

Documentation that keeps up with the day is the difference between a practice that closes at five and one that closes at seven.