AI Medical Scribe for
A one-hour nutrition assessment produces pages of detail — food recalls, anthropometrics, labs, goals. Medical Scribe writes the ADIME note from your session so the food conversation stays a conversation.
A real example of the documentation Medical Scribe generates for dietitians — ready before your patient leaves the room.
38F referred by gastroenterology for IBS-D. Height 165 cm, weight 61.8 kg, BMI 22.7, weight stable. Bloating and urgency 4-5 days weekly, worse after lunch. 24-hour recall: frequent onion, garlic, wheat, and apples; skips breakfast most days. Celiac serology negative per referral. Walks 30 minutes most days.
Altered GI function (NC-1.4) related to intake of high-FODMAP foods, as evidenced by bloating and urgency 4-5 days per week associated with identified trigger foods.
Review food and symptom diary at 4 weeks against baseline symptom frequency of 4-5 days per week. Begin reintroduction protocol if symptoms improve by half. Findings to be communicated back to the referring gastroenterologist.
Illustrative example. Every note is fully editable, and you control the format — SOAP, DAP, or your own custom template.
Referrers, payers, and your own standards expect a structured nutrition care process note with a PES statement — which means real writing after every single session.
A 24-hour recall wanders through meals, portions, brands, and exceptions. Reconstructing that detail from memory hours later is where accuracy dies.
Full clinic days leave no gaps for charting, so documentation follows you home — the classic trade of patient time now for note time later.
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.
Hour-long initial assessments, 30-minute follow-ups, telehealth check-ins between clinic days — every one is driven by open-ended conversation about food, habits, and barriers. Medical Scribe records the session and drafts the note while you move on, whether the referral is GI, renal, weight management, or oncology. You review, edit, and sign.
The generated note follows the built-in Dietitian’s Note template: Assessment covering anthropometric data, biochemical results, nutrition-focused physical findings, and dietary history; a Diagnosis section with the PES statement; Intervention spanning nutrition prescription, education, counseling strategies, and care coordination; and Monitoring and Evaluation with follow-up plans.
Nutrition care lives on dietary detail, and invented detail is worse than none. Medical Scribe documents only what the patient and you actually said — no fabricated portions, labs, or goals — so the intake history you sign is faithful to the session, every time.
Yes. The built-in Dietitian's Note template follows the nutrition care process exactly — Assessment, Diagnosis, Intervention, Monitoring and Evaluation — including the PES statement you articulate in session.
It documents the recall as the patient actually gave it — foods, portions, patterns, and exceptions — and never invents an item or a quantity. What was said in session is what appears in the note.
Yes. Medical Scribe supports SOAP, DAP, and custom formats alongside the ADIME-structured Dietitian's Note, and you can build your own template in minutes from its library of 280+ specialty templates.
Medical Scribe is HIPAA compliant, with sessions and notes encrypted in transit and at rest. It records in-person and telehealth visits across iOS, Android, Web, Apple Watch, and Mac — free to get started.
Join thousands of healthcare professionals who save hours every day with Medical Scribe.