AI Medical Scribe for
The assessment session runs 50 minutes; writing up the formulation, MSE, and risk assessment runs longer. Medical Scribe drafts the full clinical picture from the session itself.
A real example of the documentation Medical Scribe generates for counseling psychologists — ready before your patient leaves the room.
29F, GP-referred. Generalized anxiety disorder. No comorbid mood disorder identified at assessment; no prior psychological treatment.
Eight months of excessive, difficult-to-control worry centered on work performance and health, with sleep-onset insomnia, muscle tension, and irritability. GAD-7 today: 15 (moderate-severe). Symptoms followed promotion to team lead 10 months ago. Declined SSRI with GP; prefers psychological therapy. No substance use; caffeine 3-4 coffees daily.
Denies suicidal ideation, plan, or intent. No history of self-harm. No homicidal ideation. Protective factors: supportive partner, stable employment, motivated for treatment. Overall risk assessed as low; no risk management plan required at this time.
Predisposing: family history of anxiety, high self-expectations from early academic environment. Precipitating: promotion with expanded responsibility. Perpetuating: avoidance of delegation, reassurance-seeking, disrupted sleep, caffeine use. Protective: insight, motivation, stable relationship. Plan: CBT targeting worry and intolerance of uncertainty, 10 sessions, GAD-7 repeated at review.
Illustrative example. Every note is fully editable, and you control the format — SOAP, DAP, or your own custom template.
Counseling psychology depends on tracking affect, process, and the relationship in real time. Every glance at the keyboard is attention taken from the client in front of you.
What the client actually said about ideation, intent, and protective factors has to be recorded precisely. A risk section written from memory that evening is thinner than your clinical care was.
Beyond session notes, referred clients need structured care plans, reviews, and letters back to the referring GP — the same clinical content re-documented in a different format.
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 initial assessment or a mid-treatment review, Medical Scribe records the session — in the room or over telehealth — and drafts the note while the clinical detail is still exact: presenting problem, history, mental status examination, risk, and formulation. You stay in the therapeutic relationship; the draft waits for your review.
The built-in Mental Health Care Plan template structures the note the way referred care requires — Problem/Diagnosis, Clinical Details, Mental Status Examination, Risk Assessment, Formulation, the plan itself, and Review and Follow-up — and the GP MP/TCA template handles coordinated-care documentation. Custom formats for your service take minutes.
A defensible risk assessment records what the client actually said about ideation, intent, and protective factors — not a summary reconstructed hours later. Because Medical Scribe drafts from the session itself and never invents clinical content, your risk section carries the precision your judgment deserves.
Yes. Built-in Mental Health Care Plan and GP MP/TCA templates cover the referral pathway — problem/diagnosis, MSE, risk assessment, formulation, plan, and review — so the letter back to the referring GP doesn't mean re-writing the session from scratch.
Medical Scribe generates the clinical record: what was discussed, assessed, and planned. Your private process reflections stay wherever you keep them — the generated note is an editable draft you control entirely before signing.
You ask consent as you would for any scribe or supervision recording. Many clients notice the difference when you're no longer splitting attention with a notepad. Recordings are encrypted in transit and at rest, and the platform is HIPAA compliant.
No. It documents only what was actually said and observed — it never invents symptoms, scores, or risk statements. If a client didn't discuss something, it isn't in the note.
Join thousands of healthcare professionals who save hours every day with Medical Scribe.