HIPAA Compliant
AI Medical Scribe for
Addiction Medicine Specialists
MOUD decisions, risk assessments, and safety plans documented in the detail addiction medicine demands — while your eyes stay on the patient, not the chart.
Sample note
What your notes will look like
A real example of the documentation Medical Scribe generates for addiction medicine specialists — ready before your patient leaves the room.
History of Presenting Complaints
35M with opioid use disorder, severe, in early remission — week 10 on buprenorphine/naloxone 16/4mg daily. Reports no opioid use since last visit; cravings 2/10, brief, triggered by night shifts. One week of poor sleep after roster change. Attending IOP twice weekly.
Mental Status Examination
- Appearance: casually dressed, well groomed
- Speech: normal rate, volume, and tone
- Mood: 'steady' — affect congruent, full range
- Thoughts: linear and future-oriented; no SI/HI
- Insight and judgment: good
Risk Assessment
Denies suicidal ideation, intent, or plan. No overdose events since induction. Take-home naloxone kit at home; partner trained in its use. Overall risk: low.
Diagnosis
Opioid use disorder, severe, in early remission on maintenance therapy. Tobacco use disorder, moderate.
Treatment Plan
- Continue buprenorphine/naloxone 16/4mg daily; prescription provided
- Random urine drug screen collected today
- Continue IOP; discussed step-down to weekly group next month
- Offered nicotine replacement therapy; patient considering
- Review in 4 weeks
Illustrative example. Every note is fully editable, and you control the format — SOAP, DAP, or your own custom template.
Addiction medicine charts are read by more people than most
MOUD prescribing invites scrutiny
Buprenorphine and other medication decisions need clearly documented rationale, monitoring, and informed consent. When payers or regulators look, the note is your evidence.
Intakes run long, notes run longer
A new-patient evaluation covers substance use history, psychiatric history, medications, social context, MSE, and risk — an hour of conversation that becomes an hour of typing.
Stability must be re-proven every visit
Cravings, use since last visit, adherence, urine drug screens, dose adjustments — the same structured evidence, documented visit after visit, for every patient in the panel.
AI-Powered Documentation
Real-time transcription that understands medical terminology and clinical context.
Specialty Vocabulary
Recognizes terms, conditions, and procedures specific to your practice area.
Save Hours Daily
Generate comprehensive clinical notes in minutes instead of hours.
HIPAA Compliant
Enterprise-grade encryption and security to protect sensitive data.
Built-in templates
Note templates built for addiction medicine specialists
These aren't generic formats — they ship in the product today, structured around how you actually document.
Addiction Medicine Specialist's Note
History of Presenting Complaints
Past Medical & Psychiatric History
Medications
Family History
Social History
Mental Status Examination
DAP note
Data
Assessment
Plan
DARP Note
Data
Assessment
Response
Plan
Mental Health Care Plan
Patient & GP Details
Referring GP Details
Problem/Diagnosis
Clinical Details
Mental Status Examination
Risk Assessment
Plus 280+ templates across every specialty — or build your own in minutes.
From induction to maintenance
Addiction medicine spans marathon intakes, induction visits with frequent check-ins, and years of maintenance follow-ups. Medical Scribe records each encounter — in clinic or over telehealth — and drafts the note so a full day of MOUD visits doesn’t become an evening of charting. You review, edit, and sign.
Every section the specialty requires
The generated note follows the built-in Addiction Medicine Specialist’s Note: History of Presenting Complaints, Past Medical & Psychiatric History, Medications, Family and Social History, Mental Status Examination, Risk Assessment, Diagnosis, Treatment Plan, and Safety Plan. DAP and Mental Health Care Plan templates are built in as well.
Documentation that protects your prescribing
Controlled-substance treatment gets audited, and thin notes are the fastest way to trouble. Because the draft is built from the visit conversation itself, your documented rationale, consent discussions, and monitoring plan match what actually happened — and nothing is ever invented on your behalf.
Frequently asked questions
Does the note support medication for opioid use disorder documentation?
Yes. The Addiction Medicine Specialist's Note template includes dedicated Medications, Risk Assessment, Diagnosis, Treatment Plan, and Safety Plan sections, so dose decisions, monitoring, and overdose-prevention steps are captured where reviewers expect them — populated only from what was actually discussed.
Will it hold up if a payer or regulator reviews my prescribing?
The note records the clinical reasoning you voiced in the visit — response to treatment, adherence, risks weighed, plan agreed. Medical Scribe never invents findings, and you review and sign every note, so the chart reflects your actual decision-making.
My patients discuss illegal drug use. Is the recording safe?
Medical Scribe is HIPAA compliant with encryption in transit and at rest. Recordings are processed securely, you control the record, and patients consent just as they would with a human scribe in the room.
Can it handle both long intakes and quick stability visits?
Yes. A 60-minute intake produces a full evaluation — history, family and social context, MSE, diagnosis, safety plan — while a 15-minute stable MOUD visit yields a concise follow-up. The note matches the visit.
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