Why Dermatology Documentation Eats Time

Short visits and procedure-heavy schedules create lots of small notes: acne follow-ups, cryotherapy, biopsies, cosmetic consults. Each needs structured HPI, exam details, differential, plan, codes, and often image references. Context switching is costly—and templates alone can’t keep up with variability.

How AI-Powered EHR Documentation Works

1. Capture: Speak naturally (room mic or dictation) or type brief keywords.
2. Understand: The AI converts free text to structured fields (HPI, ROS, PE).
3. Draft: A complete, clinic-style note is generated using your templates.
4. Code assist: Suggested ICD-10/CPT with medical-necessity phrasing.
5. Review & sign: You edit in-line, lock, and push to claims or the patient portal.

5 High-Impact Dermatology Workflows

1) Acne Follow-Up in 60 Seconds

Dictate: “Acne vulgaris, 16F, improved on adapalene/benzoyl peroxide; dryness; add moisturizer, continue regimen, RTC 8 weeks.” AI drafts HPI, current regimen, response, tolerance, PE, and plan; maps to L70.0.

2) Cryotherapy for AKs

Quick capture of lesion count, location, freeze–thaw cycles, and consent. AI auto-phrases procedure note and aftercare; suggests CPT 17000 + 17003 units as appropriate.

3) Biopsy Documentation

Standardizes site, size, differential, method, anesthesia, hemostasis, specimen labeling, and photo link. Reduces addenda and pathology call-backs.

4) Cosmetic Consults

Transforms free-form counseling into a structured plan with risks/benefits and product lots—useful for consent and quoting.

5) Chronic Disease Care (Psoriasis/Atopic Dermatitis)

Summarizes severity scores, triggers, prior therapies, and insurance-friendly wording for PA letters—generated alongside the note.

What Clinics Typically See

• 25–45% faster note completion on day one; higher with personalization.
• Same-day close on the majority of encounters.
• Fewer denials from clearer medical necessity and consistent coding.
• Happier staff with cleaner handoffs to billing and prior-auth teams.

Privacy & Compliance: What to Expect

AI features in LegendEHR follow HIPAA safeguards: encrypted data in transit and at rest, PHI minimization, role-based access, and detailed audit logs. You control how AI is used (draft-only vs. autosuggest), and all outputs are physician-reviewed before signing.

Implementation Checklist (2–3 Hours)

1. Import or refine your clinic note templates and macros.
2. Set preferred phrasing style (concise vs. narrative; US/Canada coding).
3. Enable voice capture and test on 3 common visit types.
4. Map frequent problems to ICD-10 and procedures to CPT.
5. Decide when to prompt AI (after dictation, on save, or by hotkey).
6. Train staff on quick review & sign workflow.

FAQs

Will AI change my clinical voice?

No—LegendEHR learns your phrasing and templates. You can lock sections to prevent style drift.

Do I have to use voice?

Voice is optional. Many providers type short bullet prompts—AI still drafts the full note.

What about coding accuracy?

AI suggests ICD-10/CPT with rationale. You remain in control; selections are documented for audit.