Medical documentation today takes up a significant portion of physicians’ working time, which directly affects the organization of appointments and the way patient care is delivered.
At Łukasiewicz – AI, we are working on a solution aimed at supporting physicians in creating medical documentation while maintaining full control over the content and responsibility on the part of medical staff. The project focuses on real clinical needs and on improving work organization in healthcare facilities.
Responding to real needs of the healthcare system
The process of documenting a medical visit is an essential element of patient care; however, in practice it is one of the most time-consuming and administratively burdensome tasks. In the dynamic conditions of clinical work, physicians often need to conduct a conversation with the patient and simultaneously update IT systems, which affects both working comfort and the course of the visit.
The solution developed at Łukasiewicz – AI aims to organize and streamline this process so that documentation is created in a more efficient, consistent, and clinically aligned manner, without excessive administrative burden on physicians.
Comprehensive support for the documentation process
The designed solution goes beyond simple transcription of the physician–patient conversation. Its goal is to support the entire medical documentation process—from collecting information to preparing a structured preliminary visit summary.
The developing functionalities include, among others:
- handling multi-speaker conversations and generating preliminary visit summaries in real time,
- recognizing key medical information such as symptoms, diagnoses, or medications used,
- verifying pharmaceutical names using an integrated pharmacological database,
- intelligent content completion mechanisms in cases where statements are incomplete or unclear,
- support for creating documentation consistent with the structure of a medical summary (epikryza).
A key aspect of the project is that the system does not make medical decisions. The physician remains the final author of the documentation, with the ability to edit, correct, and approve the content in line with their own experience and clinical judgment.
Adaptation to language and clinical practice in Poland
The solution is being developed based on Polish medical data and with the realities of local healthcare institutions in mind. It takes into account both specialized terminology and the natural, often informal way in which conversations with patients are conducted.
As part of the project, work is also underway to adapt the system to regional linguistic variations, which is expected to increase its usefulness in everyday clinical practice across different parts of the country.
Safety and regulatory compliance
Data security is one of the key aspects of the project. The developed solution operates in an offline model, meaning that patient data is not transmitted outside the institution’s infrastructure.
Communication between system components is protected by advanced encryption mechanisms. This approach aligns with current and upcoming regulations, including those related to the European Health Data Space (EHDS), as well as the high requirements of medical institutions regarding the protection of sensitive information.
Testing with medical professionals
The solution is currently being tested in cooperation with physicians at the Dr. Stanisław Sakiel Burn Treatment Centre in Siemianowice Śląskie (Centrum Leczenia Oparzeń im. dr. Stansisława Sakielra). Clinical testing allows the functionality of the system to be verified in a real working environment and incorporates feedback and needs from future users.
In parallel, work is underway on a solution designed for documenting hospital rounds, which is intended to further improve the organization of medical staff work in healthcare facilities.
Media and industry interest
The work carried out at Łukasiewicz – AI has attracted interest from regional and industry media, showing that the topic of supporting physicians in creating medical documentation is one of the key challenges of modern healthcare systems.
Information about the ongoing work and tests of the developed solution can be found at:
pulsmedycyny.pl
myszkow365.pl
niepelnosprawni.pl
Polityka zdrowotna