AI Medical Scribe for
Sessions about cravings, relapse, and recovery deserve your full attention — not a laptop between you and your client. Medical Scribe drafts your SOAP or DAP note while you stay in the conversation.
A real example of the documentation Medical Scribe generates for addiction counselors — ready before your patient leaves the room.
42M with alcohol use disorder, 34 days abstinent. Reports strong cravings Friday evening after a conflict at work; used urge-surfing and called his sponsor instead of drinking. Attending AA three times weekly. Sleep improved, mood 'more level'. Taking naltrexone 50mg daily, no missed doses.
Alert, engaged, appropriately dressed. Speech clear and coherent. No signs of intoxication or withdrawal. Discussed Friday's craving episode openly and without minimization; affect congruent with content.
Progressing toward recovery goals — first high-risk trigger since intake navigated using skills rehearsed in prior sessions. Work stress remains the primary relapse risk. Motivation strong; support system actively engaged.
Illustrative example. Every note is fully editable, and you control the format — SOAP, DAP, or your own custom template.
Clients already tempted to minimize their use will say less to a counselor who's typing. The honest account of last weekend only comes out when you're fully listening.
Treatment programs and insurers expect every session note to tie back to the treatment plan — goals addressed, interventions used, client response. That structure takes time to type.
Substance use treatment records carry heightened confidentiality obligations — in the US, 42 CFR Part 2 on top of HIPAA. Notes need to be precise, professional, and protected.
Real-time transcription that understands medical terminology and clinical context.
Recognizes terms, conditions, and procedures specific to your practice area.
Generate comprehensive clinical notes in minutes instead of hours.
Enterprise-grade encryption and security to protect sensitive data.
These aren't generic formats — they ship in the product today, structured around how you actually document.
Plus 280+ templates across every specialty — or build your own in minutes.
Whether it’s a 90-minute intake, a weekly individual session, or a relapse review, Medical Scribe records the conversation — in person or over telehealth — and drafts the note before your next client sits down. No more reconstructing a caseload of sessions from memory at day’s end.
The built-in Addiction Counselor’s Note captures substance use, cravings, and triggers under Subjective, your observations of engagement and any signs of intoxication or withdrawal under Objective, and progress toward recovery goals under Assessment and Plan. Prefer DAP or DARP? Those templates are built in too.
Addiction notes follow clients through treatment programs, courts, and future providers, so wording matters. Medical Scribe documents only what was actually said — no editorializing, no invented severity — and nothing is final until you’ve reviewed and signed it.
Both. Alongside the Addiction Counselor's Note, Medical Scribe includes built-in DAP and DARP templates, a Psychology Progress Note, and support for fully custom formats — so the note comes out in the structure your program already uses.
Medical Scribe is HIPAA compliant with encryption in transit and at rest, and you control what enters the record. Every note is a draft until you review and sign it, so you decide how sensitive disclosures are worded — consistent with the heightened confidentiality substance use records require.
No. The note documents only what was said and observed in the session — it never invents clinical impressions, craving levels, or use history. Your assessment stays yours.
Yes — treat it like any scribe. You tell the client the session is being recorded to draft your note and obtain their consent. Many counselors find clients appreciate getting their undivided attention in return.
Join thousands of healthcare professionals who save hours every day with Medical Scribe.