AI-Powered Clinical Documentation: The End of Pajama Time

Every OB-GYN knows the feeling: you've just delivered a baby at 2 AM, the patient is doing well, and all you want to do is go home. But first, there's the delivery note. The procedure summary. The billing codes. Documentation that will take another 30 minutes of clicking, typing, and template-filling.

This is "pajama time"—the hours physicians spend at home completing clinical documentation that couldn't be finished during patient care. It's a major contributor to burnout, and it represents billions of dollars of physician time across the healthcare system.

The Documentation Burden

Studies consistently show that physicians spend approximately two hours on EHR documentation for every one hour of direct patient care. For OB-GYNs, the burden is particularly acute:

• Delivery notes require extensive detail about labor progression, interventions, and outcomes
• Operative reports for C-sections must document surgical technique precisely
• Billing codes must accurately reflect the complexity of care provided
• Handoff documentation ensures continuity when providers change shifts

How AI Diagnotes Works

Birth Model's Diagnotes feature uses AI to generate clinical documentation automatically from EHR data. Here's how it works:

1. Automatic Data Collection

As the patient progresses through labor and delivery, all relevant data—vital signs, cervical exams, medications, interventions—flows into Birth Model through our FHIR integration.

2. AI-Generated Draft

When the delivery is complete, Diagnotes automatically generates a comprehensive delivery note that includes all required elements in the appropriate format.

3. Intelligent Code Suggestions

The AI analyzes the clinical scenario and suggests appropriate ICD-10 and CPT codes, reducing coding errors and ensuring providers are reimbursed for the care they provide.

4. Provider Review

The provider reviews the AI-generated draft, makes any necessary edits, and signs off. What once took 30+ minutes now takes under 5.

Sample AI-Generated Note

The Revenue Impact

Beyond time savings, accurate documentation directly impacts hospital revenue. Studies show that 5-15% of potential revenue is lost to documentation deficiencies—either through undercoding, missing charges, or claim denials.

Diagnotes' intelligent coding suggestions help ensure that the complexity of care is accurately reflected in billing, reducing lost revenue while eliminating the friction of manual code lookup.

Handoff Automation

Documentation isn't just about billing—it's about communication. Birth Model also automates handoff documentation, generating comprehensive summaries for shift changes that include all relevant clinical information, pending tasks, and risk factors.