Concept prototype. All data is illustrative and fictional.
Enzo Health
QA Lead
Review queue

Review

Note level confidence and audit trail

Visit note with confidence score and supporting evidence.

Sample Agency 1 / Home Health / OASIS

Margaret Ellis, routine visit note

Excerpt, 5 of 10 statements shown

Needs review

  • Margaret Ellis tolerated the visit well and reports steady pain at a moderate level.Audio 04:12

  • Ambulation observed at roughly 100 feet with a front wheeled walker and standby assist.Audio 09:30

  • Wound to left lower leg appears smaller than the prior visit with no drainage noted.

    Flagged: No matching statement found in the visit audio.

    • Visit audioNo matching statement in transcriptNot found

      Clinician"How is the leg feeling today?"

      Patient"Less sore than last week, I think."

    • Prior visit notePrior visit, 7 days agoSupports

      Wound left lower leg 3.0 x 2.0 cm, scant serous drainage.

  • Caregiver present for the full visit and able to repeat back the medication schedule.Audio 15:48

  • Assistance level for bathing recorded as independent.

    Flagged: Prior chart recorded this as needing assistance. Change is unexplained.

    • Prior visit notePrior visit, 7 days agoConflicts

      Bathing: requires assistance of one for tub transfer.

    • Visit audioTranscript 18:05Supports

      Patient"My daughter still helps me get in and out of the tub."

Confidence score

80%

Based on evidence matched across visit audio and the prior chart.

Outcome

Needs human review

Reason: 2 of 10 statements need review. 1 has no matching visit audio and 1 conflicts with the prior chart without an explanation. A note clears to auto approve only when every statement traces to visit audio and is consistent with the prior chart, or the change is explained.

Auto approve criteria: 10 of 10 statements matched, 0 items flagged, reviewer sees a summary rather than the full note.

Resolve 3 remaining items to approve

Enzo QA

Primary diagnosis and sequencing

Coding review pending

Documented

  1. 1E11.9Type 2 diabetes mellitus without complications
  2. 2I10Essential (primary) hypertension

Suggested

  1. 1E11.622Type 2 diabetes mellitus with other skin ulcer
  2. 2L97.822Non-pressure chronic ulcer of other part of left lower leg with fat layer exposed
  3. 3I10Essential (primary) hypertension

Why this suggestion

The H&P documents the left lower leg wound as a diabetic ulcer, and wound care is the focus of this episode. The ICD-10 'with' convention links diabetes and the ulcer, so E11.622 is sequenced first, with L97.822 added for site and severity.

  • History and physicalH&P, hospital dischargeSupports

    Diabetic ulcer of the left lower leg, fat layer exposed. Home health for wound care.

  • ReferralReferral, received 12 days agoSupports

    Skilled nursing for wound care, left lower leg.

Matched against visit audio

9 of 10 statements traced to the recorded visit

Each clinical statement in the draft is lined up with a moment in the visit recording, with the referral and H&P also checked where available. One statement has no matching audio.

Matched against prior chart

9 of 10 statements consistent with prior notes

Functional status and medication lines are compared with the previous visit record, plus the referral and H&P where available. One line differs from the last note without an explanation.

Items flagged for human review

2 items flagged

1 statement has no matching audio and 1 conflicts with the prior chart. A reviewer sees these first, not the whole note.

Audit trail

Note activity

  • No activity recorded for this note yet.