AI Medical Scribe for
A good nutrition consult is a detailed conversation — 24-hour recalls, weight history, readiness to change. Medical Scribe listens and drafts a complete ADIME note, PES statement included, so you can counsel instead of type.
A real example of the documentation Medical Scribe generates for general dietitians — ready before your patient leaves the room.
Excessive carbohydrate intake related to reliance on takeaway meals and sugar-sweetened beverages, as evidenced by HbA1c 8.2%, BMI 30.9, and diet history showing ~2,800 kcal daily intake with frequent refined carbohydrates.
Illustrative example. Every note is fully editable, and you control the format — SOAP, DAP, or your own custom template.
Assessment, Diagnosis, Intervention, Monitoring and Evaluation — every consult has to be sorted into the Nutrition Care Process, and a food recall scribbled during the session still needs restructuring afterward.
A 24-hour recall plus usual patterns, portion sizes, food preferences, and food security status is a lot of granular detail. Miss it in the moment and the assessment loses its foundation.
Behavior change is built on rapport. Motivational interviewing while typing an anthropometric table into the chart undermines the very engagement you're trying to create.
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 assessments run long and follow-ups run tight — and both live or die on conversational detail. Medical Scribe records the session (in person or telehealth) and drafts the note from it, so the food recall, weight history, and the goals your client committed to are captured while you focus on counseling, not keystrokes.
The generated note follows the built-in General Dietitian’s Note template: Assessment covering anthropometrics, biochemical data, nutrition-focused physical findings, and dietary history; Diagnosis with the PES statement; Intervention spanning the nutrition prescription, education, and counseling strategies; and Monitoring and Evaluation with progress measures and the follow-up plan.
Dietetic notes justify ongoing care — to referrers, insurers, and your own future self. Because the note documents only what was said in the session, your PES statement rests on evidence actually gathered, not boilerplate. You review and sign each note, and the reasoning chain from assessment to intervention stays intact.
Yes. The built-in General Dietitian's Note template follows the Nutrition Care Process — Assessment, Diagnosis, Intervention, Monitoring and Evaluation — and includes the PES statement when the problem, etiology, and signs were established in the session. It never invents a diagnosis you didn't make.
Everything spoken in the consult — 24-hour recall items, portion estimates, meal patterns, food preferences, food security — is drafted into the Assessment. Anthropometric and biochemical data you discuss aloud land there too, exactly as stated.
Yes. It records in-person and telehealth visits, with apps for iOS, Android, Web, Apple Watch, and Mac, and it works in 57 languages — useful when counseling patients in their preferred language.
Medical Scribe is HIPAA compliant with encryption in transit and at rest. Every note is a draft you review and approve before it goes anywhere.
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