Understand the terms used in AI-assisted clinical documentation.
Straightforward definitions that help physicians and practices evaluate transcription, drafts, professional review, telemedicine, and privacy more safely.
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Glossary
- AI for physicians
- The use of artificial intelligence systems to support tasks in medical practice. In Zello Life, the focus is on documentation and information organization, not replacing clinical decisions.
- Assisted clinical documentation
- A workflow in which technology helps capture, transcribe, or structure information while the professional reviews and approves the final record.
- Medical transcription
- Converting speech from a consultation into text. A raw transcript still contains repetition and context that must be organized before it becomes a clinical document.
- Clinical draft
- Initial text generated or organized by the platform. It must remain editable and must not be shared as the final version without physician review.
- Medical review
- The stage in which the professional checks identification, the source of information, findings, hypotheses, care plan, dosages, and instructions before approving the document.
- SOAP template
- A record structure divided into subjective, objective, assessment, and plan. It is common in progress and follow-up notes but must be adapted to the case and the professional's practice.
- Clinical history
- An organized record of the clinical history, which may include the complaint, progression, history, medications, allergies, context, and other data relevant to care.
- Telemedicine
- The remote provision of medical services through information and communication technologies, within applicable legal and professional rules.
- Sensitive personal data
- A category defined by the LGPD that includes, among other things, health-related data when linked to a natural person.
- Data controller
- The agent that makes the main decisions about the purpose and essential elements of personal data processing. The role depends on the actual activity in the specific case.
- Data processor
- The agent that processes personal data on behalf of the controller and according to its instructions, within the limits established by the LGPD and the relationship between them.
- Data retention
- The period and rules used to retain audio, transcripts, drafts, documents, logs, and backups before deletion, anonymization, or another intended destination.