The Complexity of Inpatient Care

Every healthcare setting has its own unique demands. 

Outpatient visits, emergency care, and inpatient medicine all look very different. Among these, the inpatient environment is one of the most complex. Patients often have multiple, complicated conditions that require continuous monitoring. And collaborative care teams of hospitalists, nurses, specialists, and case managers work together in service of the patient, with frequent handoffs between clinicians.

For hospitalists, documentation is both constant and critical. From the admission history and physical, to daily progress notes and discharge summaries, every note must be complete and timely. 

These documents are also more than a record of care. They drive patient safety, continuity across teams, and reimbursement accuracy. Gaps or errors can create risks for patients, extra workload for clinicians, and financial loss for health systems.

The Pressures of Inpatient Documentation

Hospitalists face heavy demands on their time. They manage high patient volumes, coordinate across disciplines, and handle admissions and discharges around the clock. Documentation is layered on top of these responsibilities. Notes must include suspected and probable conditions, integrate new labs and consults, and reflect the latest changes in patient status.

Unlike in many outpatient settings, inpatient documentation is directly tied to compliance and revenue cycle performance. Coders and CDI specialists can only code what physicians document. If details about comorbidities or complexity are missed, the result can be a payer denial, insufficient DRG, or additional queries sent back to the physician. This cycle adds administrative inefficiency, delays care, and contributes to physician burnout.

Ambience’s AI Platform for Inpatient Care

Rather than adapting outpatient solutions to the hospital floor, Ambience’s inpatient suite of AI technology was designed around the realities of hospitalist workflows and the needs of health systems.

• Epic-integrated workflows: Ambience supports all required inpatient documentation, including H&Ps, progress notes, hospital courses, and discharge summaries.

• Chart-aware notes: The system brings forward relevant chart data such as consults, orders, labs, and vitals, so documentation is comprehensive and handoffs are safer.

• Coding and compliance built-in: Notes are UHDDS-compliant from the start, reducing CDI queries and minimizing payer scrutiny.

• Real-time guidance: Nudges clinicians to document ICD-10 codes with greater specificity and capture missed secondary diagnoses supporting CC/MCCs

By embedding compliance and coding support directly into the documentation process, Ambience reduces downstream issues and ensures that records are both clinically useful and financially accurate.

Benefits for Patients, Clinicians, and Health Systems

For patients, the impact of the right AI technology is deeply personal. Clearer and more complete documentation supports safer handoffs between clinicians and ensures continuity of care across the hospital stay. Discharge instructions are more thorough and improve transitions home or to another facility. Most importantly when hospitalists spend less time typing and more time present at the bedside, patients feel heard, supported, and cared for.

For clinicians, the benefits are immediate. Documentation is faster, more accurate, and less stressful. Progress notes and discharge summaries are completed on time, reducing after-hours work. Fewer CDI queries also mean fewer interruptions in daily workflows. Furthermore, hospitalists can spend more time at the bedside focusing on direct patient care.

For health systems, accurate documentation at the point of care leads to better MCC and CC capture, fewer denials, and improved DRG classification. Coders and CDI nurses can work more efficiently, focusing on high-value cases instead of chasing missing details. By aligning documentation with payer expectations from the start, Ambience strengthens both compliance and performance.

Setting a Higher Standard for Inpatient AI

By combining AI scribing, real-time coding support, and CDI compliance into a single Epic-integrated solution – built specifically for inpatient clinicians – Ambience sets a new standard for inpatient documentation. 

The result is a system that helps clinicians work at the top of their license, while giving health systems the assurance of accurate, compliant, and timely documentation.

With the right AI technology, the inpatient care setting does not have to feel like a constant trade-off between patient time, documentation, and compliance.