AI Medical Scribe for
Carb ratios, glucose logs, and food recalls make diabetes MNT visits dense with numbers. Medical Scribe turns the session into a complete ADIME note — PES statement included — while you stay focused on the patient.
A real example of the documentation Medical Scribe generates for diabetes dietitians — ready before your patient leaves the room.
58M with type 2 diabetes, referred for medical nutrition therapy. HbA1c 8.4%, down from 9.1%. Weight 96.2 kg, BMI 31.4. On metformin 1000mg BID and semaglutide 0.5mg weekly. Food recall: sweetened coffee drinks twice daily, late-night snacking, eating out 4-5 times weekly. Walks 20 minutes 3 days per week.
Excessive carbohydrate intake (NI-5.8.2) related to limited knowledge of carbohydrate sources, as evidenced by food recall showing approximately 280g carbohydrate daily and HbA1c of 8.4%.
Patient to log meals and fasting glucose 4 days per week. Repeat HbA1c ordered by PCP before next visit. Follow up in 4 weeks to review logs and adjust carbohydrate distribution.
Illustrative example. Every note is fully editable, and you control the format — SOAP, DAP, or your own custom template.
Carb targets, A1c trends, medication doses, and glucose readings all have to land in the note accurately — reconstructing them from memory after clinic is where errors creep in.
Referring physicians and payers expect a proper nutrition care process note with a PES statement and measurable goals — not a free-text summary.
Each visit must document progress against the last set of goals to support continued MNT referrals — a running thread that's tedious to maintain by hand.
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.
Initial MNT assessments, carb-counting education, insulin-adjustment coordination, and four-week follow-ups all run on conversation — the last place you want a keyboard between you and the patient. Medical Scribe records the session, in person or telehealth, and drafts the note before your next appointment. You review, edit, and sign.
The generated note follows the built-in Diabetes Dietitian’s Note template: Assessment (anthropometrics, labs, dietary and activity history), Diagnosis with PES statement, Intervention (nutrition prescription, education, counseling, care coordination), and Monitoring and Evaluation. Your food recall detail and goal-setting land where the NCP says they should.
A wrong carb ratio or A1c in the chart isn’t a typo — it’s a clinical problem. Medical Scribe documents only the values actually spoken in the visit and never fabricates data, so the glucose trends and targets in your note match the conversation exactly.
Yes. The built-in Diabetes Dietitian's Note template follows the nutrition care process — Assessment, Diagnosis, Intervention, Monitoring and Evaluation — and captures the PES statement you formulate during the visit.
The note records measurable goals, interventions, and progress against prior goals in structured sections — the trail referrers and payers look for. You review and sign before anything enters the chart.
It documents the exact values spoken in the session and never invents a number, dose, or lab result. Anything you didn't say simply doesn't appear, so what you sign is what was discussed.
Yes. Medical Scribe records in-person and telehealth visits, with apps for iOS, Android, Web, Apple Watch, and Mac. It's HIPAA compliant and encrypted in transit and at rest.
Join thousands of healthcare professionals who save hours every day with Medical Scribe.