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Care Plan 2.0: Care Team Review & AI Call Notes

Module: Care Plan 2.0

Written by HealthArc Support

Overview

The Care Team Review and AI Call Notes sections are designed to improve collaboration, streamline documentation, and ensure that every member of the patient's care team has access to consistent, up-to-date information.

The Care Team Review section enables care coordinators and providers to review the completed Care Plan before physician approval, ensuring that clinical information is complete, accurate, and aligned with the patient's current health status.

The AI Call Notes feature leverages artificial intelligence to automatically generate structured summaries of patient interactions and recommend follow-up tasks based on the conversation. These AI-generated notes reduce documentation time while helping maintain comprehensive clinical records.


Before You Begin

Before completing these sections, ensure that:

  • The Care Plan has been substantially completed.

  • Patient information has been reviewed.

  • Assessments and SDOH documentation are complete.

  • SMART Goals and Interventions have been finalized.

  • Risk Classification has been assigned.

  • Any patient encounters or care coordination calls have been completed.


Navigation

  1. Log in to the HealthArc Portal.

  2. Navigate to Patients.

  3. Select the desired patient.

  4. Open the Care Plan tab.

  5. Open the active draft Care Plan.

  6. Navigate to:

    • Care Team Review

    • AI Call Notes


Care Team Review

Overview

The Care Team Review section serves as the final internal review stage before a Care Plan is submitted for physician approval.

Its purpose is to ensure that all clinical documentation has been completed accurately and that the proposed care plan reflects the patient's current medical condition, goals, and care needs.

Organizations with multiple care coordinators, nurses, and supervisors may use this step as part of their internal quality assurance process.


Why Care Team Review Is Important

A structured review process helps to:

  • Improve documentation quality.

  • Ensure consistency across care coordinators.

  • Identify missing or incomplete information.

  • Verify clinical accuracy.

  • Confirm that interventions align with patient goals.

  • Reduce physician review time.

  • Improve compliance with care management documentation standards.


Information to Review

During Care Team Review, verify the following sections have been completed:

✓ Personal Details

✓ Family & Social History

✓ Lifestyle & Risk Factors

✓ Medications

✓ Allergies

✓ Behavioral Symptoms

✓ Assessments

✓ Barriers to Care

✓ Social Determinants of Health

✓ Vitals

✓ Preventive Services

✓ SMART Goals

✓ Interventions

✓ Self-Management Tasks

✓ Risk Classification


Care Team Review Workflow

Step 1 – Review Patient Information

Confirm that:

  • Demographics are current.

  • Contact information is accurate.

  • Program enrollment is correct.

  • Primary care provider information is up to date.


Step 2 – Review Clinical Documentation

Verify that:

  • Diagnoses are reflected appropriately.

  • Medication lists are current.

  • Allergies have been reviewed.

  • Behavioral observations are documented.


Step 3 – Review Assessments

Ensure:

  • Required assessments have been completed.

  • Assessment scores are documented.

  • Significant findings are addressed through interventions.


Step 4 – Review SDOH

Confirm that:

  • Social needs have been documented.

  • Barriers to care have been identified.

  • Appropriate referrals or interventions have been added where necessary.


Step 5 – Review Goals

Verify that:

  • Every SMART Goal is measurable.

  • Goals are patient-specific.

  • Goals align with diagnoses.

  • Goals are achievable.


Step 6 – Review Interventions

Ensure that:

  • Each intervention supports one or more SMART Goals.

  • No duplicate interventions exist.

  • Clinical actions are realistic and appropriate.


Step 7 – Review Self-Management

Confirm that:

  • Tasks are understandable.

  • Patients can reasonably complete them.

  • Tasks reinforce clinical goals.


Step 8 – Review Risk Classification

Verify that the assigned risk level accurately reflects:

  • Clinical complexity.

  • Social factors.

  • Functional status.

  • Overall patient condition.


Step 9 – Save the Review

After confirming all information:

  1. Save the Care Team Review.

  2. Proceed to physician approval when organizational workflow requires it.


Internal Collaboration

Care Team Review promotes collaboration among:

  • Care Coordinators

  • Nurses

  • Care Managers

  • Clinical Supervisors

  • Physicians

  • Specialists

Each team member contributes to developing a comprehensive care plan while maintaining documentation quality.


Documentation Checklist

Before completing the review, confirm that:

☐ Patient demographics are accurate.

☐ Medication list is current.

☐ Allergies have been verified.

☐ Recent assessments are included.

☐ SDOH documentation is complete.

☐ Barriers to care have interventions.

☐ SMART Goals are measurable.

☐ Interventions are appropriate.

☐ Self-management tasks are realistic.

☐ Risk Classification has been assigned.

☐ Clinical notes are complete.

☐ Patient education has been documented where appropriate.


AI Call Notes

Overview

The AI Call Notes feature helps reduce documentation time by automatically generating structured clinical notes after a completed patient interaction.

Rather than manually documenting every conversation, users can generate an AI-assisted summary that captures key discussion points and recommends follow-up actions.

The generated content should always be reviewed and edited by the care coordinator before it becomes part of the patient's permanent clinical record.


Benefits of AI Call Notes

AI-assisted documentation helps:

  • Reduce manual typing.

  • Standardize documentation.

  • Improve note consistency.

  • Capture important discussion points.

  • Suggest follow-up activities.

  • Improve documentation efficiency.


Supported Patient Encounters

AI Call Notes may be used following:

  • Monthly CCM calls

  • RPM follow-up calls

  • PCM encounters

  • APCM visits

  • Care coordination calls

  • Wellness follow-ups

  • Chronic disease management calls

Availability depends on your organization's configuration.


Generating AI Call Notes

After completing a patient interaction:

  1. Navigate to AI Call Notes.

  2. Select the completed encounter.

  3. Click Generate AI Notes.

  4. Wait while the system processes the conversation.

  5. Review the generated summary.

The generated note typically includes:

  • Reason for the call

  • Patient concerns

  • Symptoms discussed

  • Education provided

  • Care coordinator recommendations

  • Follow-up actions

  • Next steps


Reviewing AI-Generated Notes

AI-generated documentation should always be reviewed before saving. Verify that:

  • Patient identifiers are correct.

  • Clinical information is accurate.

  • Recommendations reflect the actual discussion.

  • No important information is missing.

  • Medical terminology is appropriate.

  • Grammar and formatting are acceptable.

If necessary, edit the note before saving it to the Care Plan.


AI-Generated Tasks

In addition to summarizing conversations, Care Plan 2.0 can recommend follow-up activities based on the documented encounter. Suggested tasks may include:

  • Schedule a follow-up call.

  • Contact the primary care provider.

  • Arrange specialist referral.

  • Review medication adherence.

  • Repeat blood pressure monitoring.

  • Order additional assessments.

  • Provide patient education.

  • Verify preventive screenings.

  • Follow up on abnormal RPM readings.

These suggestions should be reviewed and accepted or modified before being assigned.


Editing Suggested Tasks

Users may:

  • Edit task descriptions.

  • Change priority.

  • Assign tasks to another team member.

  • Update due dates.

  • Remove unnecessary recommendations.

  • Add additional tasks manually.


Saving AI Documentation

Once reviewed:

  1. Make any necessary edits.

  2. Save the AI-generated note.

  3. Save accepted follow-up tasks.

  4. Continue with physician review or finalize the Care Plan.


Best Practices

Care Team Review

  • Complete all clinical sections before initiating the review.

  • Use a standardized review process for every patient.

  • Verify all imported and template-generated information.

  • Ensure goals, interventions, and risk classification are consistent.

  • Resolve documentation gaps before physician approval.

AI Call Notes

  • Treat AI-generated notes as a draft rather than a final clinical record.

  • Review every generated note for accuracy and completeness.

  • Add any clinically significant details that may not have been captured.

  • Remove duplicate or irrelevant information.

  • Ensure documentation reflects the actual patient encounter.


Troubleshooting

I cannot access the Care Team Review section.

Verify that the Care Plan has been created and that your user role includes permission to review or edit care plans.


The AI Call Notes option is unavailable.

AI-assisted documentation may not be enabled for your organization or licensing tier. Contact your administrator to verify feature availability.


The generated summary is incomplete.

AI-generated notes are intended to assist documentation and may not capture every detail. Review the patient encounter and manually add any missing clinical information before saving.


Can I edit AI-generated notes?

Yes. AI-generated notes are fully editable and should always be reviewed before they are saved as part of the patient's permanent record.


Are AI-generated tasks automatically assigned?

No. Suggested follow-up tasks should be reviewed, modified if necessary, and accepted by the care coordinator before they become part of the patient's workflow.

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