AI Medical Scribe for
OT, exercise physiology, podiatry, speech — whatever your discipline, session notes eat into treatment time. Medical Scribe documents goals, treatment delivered, and the plan while your hands stay on the work.
A real example of the documentation Medical Scribe generates for allied health professionals — ready before your patient leaves the room.
55F, six weeks post right total knee replacement. Reports morning stiffness and difficulty on stairs; pain 3/10 at rest, 5/10 after her daily walk. Sleeping through most nights. No wound concerns.
Short term: manage a full flight of stairs reciprocally within 4 weeks. Long term: return to lawn bowls by three months post-op.
Right knee AROM 5-105° flexion (up from 10-95° last week). Quads lag resolved. 30-second sit-to-stand: 9 repetitions. Gait: mild antalgic pattern, no aid indoors.
Continue twice-weekly sessions for 2 weeks, then reassess. HEP updated: heel slides 3x10 daily, step-ups 3x8 alternate days. Progress to 20cm block next session if pain remains under 4/10.
Illustrative example. Every note is fully editable, and you control the format — SOAP, DAP, or your own custom template.
Thirty- to forty-five-minute appointments stacked all day leave no gap for charting — so session write-ups spill into lunch breaks and evenings.
Referrers, insurers, and funding schemes expect every note to show documented goals, treatment provided, and measurable progress. Missing structure means queried claims.
Patient goals, objective measures, treatment delivered, home program, plan — essential for continuity, mind-numbing to retype twenty times a day.
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.
Allied health sessions are physical: your hands are mobilizing a joint, guiding a transfer, or supervising an exercise set. Medical Scribe records the session from your phone or watch and drafts the note as you work — initial assessments, progress reviews, and discharge summaries alike — so the write-up is waiting when the client leaves.
The built-in Allied Health Professional’s Note structures the draft into Patient Information, Medical and Social History, Current Condition/Complaint, Patient Goals, Objective, Treatment, Assessment, and Plan — with treatment delivered this session kept separate from the home program and future plan, the way clean clinical records demand.
Continuity of funded care rests on showing measurable change: ROM gains, outcome scores, goals progressed. Because the note is drafted from what you actually said and measured in the session, your records build an honest, consistent progress trail — reviewed and signed by you before anything is filed.
Yes. The Allied Health Professional's Note is deliberately discipline-agnostic — goals, objective measures, treatment, plan — and there are 280+ built-in templates including a dedicated OT Note. If your service has its own format, a custom template takes minutes.
It documents the numbers you say during the session — ROM in degrees, repetitions, hold times, outcome measure scores — in the note's Objective and Treatment sections. Anything you didn't state simply isn't in the draft, so nothing gets invented.
The generated note separates Patient Goals, Treatment delivered this session, Assessment of progress, and Plan — the structure referrers and funding bodies look for when they review whether therapy is goal-directed. You review and sign before it goes in the record.
Yes. Medical Scribe is HIPAA compliant, with recordings encrypted in transit and at rest, and works for in-person and telehealth sessions across iOS, Android, Web, Apple Watch, and Mac.
Join thousands of healthcare professionals who save hours every day with Medical Scribe.