AI Medical Scribe for
A new-diagnosis consult covers pathology, imaging, surgical options, and a frightened patient's questions — then needs a letter-perfect note. Medical Scribe drafts it from the conversation so your attention stays on the patient.
A real example of the documentation Medical Scribe generates for breast surgeons — ready before your patient leaves the room.
52F referred with a screen-detected 1.4 cm mass, right breast at 10 o'clock. Core biopsy: invasive ductal carcinoma, grade 2, ER 95%, PR 80%, HER2-negative. No palpable lump noticed by patient; no nipple discharge or skin change. No prior breast surgery. Mother had breast cancer at 61. Non-smoker; no anticoagulants.
Discussed breast conservation versus mastectomy with equivalent survival; patient elects conservation. Risks reviewed: bleeding, infection, seroma, lymphoedema with SLNB, margin re-excision, change in breast shape. Consent signed. Written information provided; breast care nurse contact given.
Illustrative example. Every note is fully editable, and you control the format — SOAP, DAP, or your own custom template.
Walking a newly diagnosed patient through lumpectomy versus mastectomy, sentinel node biopsy, and reconstruction requires full presence. Typing through it costs trust at the worst possible moment.
Receptor status, grade, imaging, clip placement, genetics referral, MDT recommendation — a breast surgical note pulls the entire diagnostic picture into one coherent plan, every time.
The record of what risks were discussed — margins and re-excision, lymphoedema, cosmetic change — is your medicolegal account of informed consent. It has to reflect the actual conversation.
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.
The new-diagnosis consult is where breast surgery is really practiced: explaining pathology, weighing conservation against mastectomy, answering the questions behind the questions. Medical Scribe records the consultation — clinic or telehealth — and drafts the complete surgical note afterwards, so nothing about that hour is spent facing a screen.
The built-in Breast Surgeon’s Note template organizes each consult into Subjective, Objective, and a per-condition Assessment & Plan — presenting history and biopsy results, examination and imaging findings, then the operative plan, pre-operative preparation, post-operative care, and referrals, with consent and patient concerns in additional notes. Custom formats, including your own clinic letter structure, take minutes to build.
If a margin needs re-excision or a complication occurs, the chart’s account of what was discussed becomes the record that matters. Medical Scribe documents the consent conversation as it actually happened — the specific risks named, the alternatives offered, the patient’s choice — and never invents a detail, so your note and your counseling are the same thing.
Yes. The risks, alternatives, and patient decisions actually discussed in the consult are documented in the note's assessment, plan, and additional notes — as spoken, never reconstructed or embellished — giving you a contemporaneous consent record you review and sign.
The note contains exactly what was stated in the consultation — ER/PR percentages, HER2 status, grade, clinical stage — placed in the structured Breast Surgeon's Note format. It never invents a pathology result, and you verify everything before it enters the chart.
Yes. A new-diagnosis consult generates a full Subjective, Objective, Assessment & Plan note; a post-operative review produces a concise note covering wound checks, drain output, pathology discussion, and next steps. Telehealth follow-ups are recorded the same way as clinic visits.
Medical Scribe is HIPAA compliant, with encryption in transit and at rest. Recordings exist solely to draft the note, and nothing is final until you sign it.
Join thousands of healthcare professionals who save hours every day with Medical Scribe.