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 3 / Home Health / OASIS

Rosa Delgado, resumption of care note

T. Nguyen, PT, Today

Needs review

  • Metoprolol dose increased to 50 mg daily per physician order.

    Flagged: Medication change not mentioned in the visit audio.

    • Visit audioNo matching statement in transcriptNot found

      Clinician"Are you still taking the heart pill every morning?"

      Patient"Yes, the little white one."

    • ReferralReferral, received 12 days agoConflicts

      Metoprolol tartrate 25 mg by mouth twice daily.

    • History and physicalH&P, hospital dischargeConflicts

      Discharge medications: metoprolol 25 mg twice daily. No dose change ordered.

  • Fall risk assessed as low; patient ambulating independently in the home.

    Flagged: Fall risk lowered from prior chart without an explanation.

    • Prior visit notePrior visit, 9 days agoConflicts

      Fall risk high. Two falls in the past 3 months. Uses walker at all times.

    • Visit audioTranscript 07:22Conflicts

      Patient"I left the walker in the bedroom, I only use it at night now."

    • History and physicalH&P, hospital dischargeConflicts

      Admitted after a fall at home. Gait unsteady on discharge.

  • Vital signs: BP 132/78, HR 76, SpO2 96% on room air.

    Flagged: Vital signs line has no matching audio.

    • Visit audioNo matching statement in transcriptNot found

      Clinician"Let me get your blood pressure and oxygen."

      (No readings spoken aloud.)

    • Prior visit notePrior visit, 9 days agoConflicts

      BP 148/86, HR 82, SpO2 94% on room air.

  • 7 statements supported by visit audio and prior chart

Confidence score

70%

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

Outcome

Needs human review

Reason: 3 of 10 statements need review. 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 4 remaining items to approve

Enzo QA

Primary diagnosis and sequencing

Coding review pending

Documented

  1. 1I10Essential (primary) hypertension
  2. 2Z91.81History of falling

Suggested

  1. 1I11.0Hypertensive heart disease with heart failure
  2. 2I50.32Chronic diastolic (congestive) heart failure
  3. 3Z91.81History of falling

Why this suggestion

The referral and H&P document chronic diastolic heart failure alongside hypertension. ICD-10 guidelines presume a causal link between the two, so I11.0 is sequenced first with I50.32, and I10 should not be used.

  • History and physicalH&P, hospital dischargeSupports

    Chronic diastolic heart failure with hypertension. Admitted after a fall at home.

  • ReferralReferral, received 12 days agoSupports

    Focus of care: heart failure management and fall prevention.

Matched against visit audio

8 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.

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.

Items flagged for human review

3 items flagged

2 with no matching audio and 1 that conflict with the prior chart. A reviewer sees these first.

Audit trail

Note activity

  • No activity recorded for this note yet.