AI Medical Scribe for
Clinic consults, pre-op counselling, and post-op reviews each end in a note that has to justify an operation. Medical Scribe drafts the Subjective, Objective, and Assessment & Plan while you talk the patient through it.
A real example of the documentation Medical Scribe generates for colorectal surgeons — ready before your patient leaves the room.
58M referred for grade III internal hemorrhoids with intermittent bright red rectal bleeding x 6 months, worse with defecation. Failed 3 months of fiber supplementation, sitz baths, and topical hydrocortisone. Colonoscopy 3 weeks ago: grade III internal hemorrhoids, no proximal source, no malignancy. PMH: atrial fibrillation on apixaban 5mg BID. No prior abdominal surgery. Never smoker. NKDA.
Discussed risks including post-operative pain, bleeding, urinary retention, infection, and rare incontinence or anal stenosis; alternatives including continued conservative care and stapled hemorrhoidopexy reviewed. Patient verbalized understanding; consent form signed.
Illustrative example. Every note is fully editable, and you control the format — SOAP, DAP, or your own custom template.
New referrals, scope results, and post-op checks stack up on clinic days — and every consult still needs a complete surgical note before the next theatre list.
The risks, benefits, and alternatives you discussed for a hemorrhoidectomy or anterior resection need to appear in the note as discussed — thin consent documentation is a medicolegal exposure.
A single visit covers scope findings, anticoagulation management, the operative decision, pre-op preparation, and the post-op plan. Reconstructing all of it from memory takes longer than the consult did.
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.
A colorectal clinic runs on decisions: operate or observe, excise or band, resect or refer. Medical Scribe records the consult — in person or telehealth — and drafts a complete note in the built-in Colorectal Surgeon’s Note template: presenting complaint, scope and imaging results, examination, and the operative plan you actually agreed with the patient. You review, edit, and sign.
The generated note follows the template’s Subjective, Objective, and Assessment & Plan sections — including anticoagulant management, differential diagnosis, planned investigations, pre-operative preparation, and the post-operative care plan. When one visit covers multiple surgical issues, each gets its own assessment, exactly as the template structures them.
When an operation is questioned later, the record of what you told the patient matters most. Medical Scribe documents the risks, benefits, and alternatives discussion from what was actually said — never inferred, never padded — so your consent documentation reflects the conversation you genuinely had.
Yes. The built-in Colorectal Surgeon's Note template documents patient education and informed consent alongside the Assessment & Plan, so the risks, benefits, and alternatives you actually discussed appear in the note — and only what was actually said gets documented.
Yes. A new referral generates a full consult note with history, examination, and operative plan; a post-op review produces a focused note on wound healing, bowel function, and recovery. The note matches the visit type, not a one-size template.
Yes. DRE and anoscopy findings, abdominal examination, and scope results you verbalize during or after the exam are captured in the Objective section. It never invents clinical findings — you review and sign before anything enters the chart.
Medical Scribe is HIPAA compliant with encryption in transit and at rest. It records in-person and telehealth consults on iOS, Android, Web, Apple Watch, and Mac, and every note is an editable draft until you sign it.
Join thousands of healthcare professionals who save hours every day with Medical Scribe.