AI Medical Scribe for
Menstrual, obstetric, and sexual histories take a full conversation to gather — and too long to type. Medical Scribe drafts your complete gyn note, from HPI to pelvic exam findings to plan, while you stay face-to-face with your patient.
A real example of the documentation Medical Scribe generates for gynecologists — ready before your patient leaves the room.
42F referred for heavy menstrual bleeding x6 months. Cycles q26 days, bleeding 8 days with flooding and clots; soaking through super-plus tampon hourly on day 2. G2P2, both SVD. No intermenstrual or postcoital bleeding. Pap current and negative. Reports fatigue; no dizziness or syncope. Does not desire future pregnancy. Meds: none. NKDA. Non-smoker.
Abnormal uterine bleeding, most consistent with leiomyomas (AUB-L). Suspect iron deficiency given flooding and fatigue. Differential includes adenomyosis and endometrial pathology; endometrial sampling indicated given age and bleeding pattern.
Illustrative example. Every note is fully editable, and you control the format — SOAP, DAP, or your own custom template.
Menstrual, obstetric, sexual, and contraceptive histories all belong in the chart — re-documenting them for every AUB workup or annual visit is where clinic days go to die.
Patients discussing bleeding, painful intercourse, or fertility worries disclose less to the back of a laptop. The exam-room screen works against the visit.
IUD insertions, colposcopies, and endometrial biopsies each add consent discussions, findings, and aftercare instructions that have to be documented precisely.
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.
An annual well-woman exam, an AUB workup, a contraception consult, and a post-op check produce very different notes. Medical Scribe records the visit — in person or telehealth — and drafts the right one, capturing menstrual dates, gravida/para, exam findings, and the plan you actually discussed. You review, edit, and sign before anything reaches the chart.
The generated note follows the built-in Gynecologist’s note template: a Subjective section spanning gynecological, obstetric, sexual, and medication history; an Objective section with breast and pelvic exam subsections; Assessment with diagnoses; and a Plan covering investigations, treatment, follow-up, and patient education. Gynae & Women’s Health and Mirena Insertion Consent templates are built in too.
In a specialty where a missed detail about postcoital bleeding or an undocumented consent discussion has real consequences, the scribe’s discipline matters: it documents only what was said and observed. If a finding is not in the conversation, it is not in the note — and you sign off on every word.
Yes. The built-in Gynecologist's note template has a dedicated Objective section with breast and pelvic examination subsections — external genitalia, vagina, cervix, uterus, and adnexa — populated only from what you actually dictate or discuss during the exam.
Yes. Alongside the Gynecologist's note and Gynae & Women's Health templates, there is a Mirena Insertion Consent template that captures the consent discussion — alternatives, contraindications, risks, and aftercare instructions — as it happens. Custom procedure templates take minutes to build.
Medical Scribe is HIPAA compliant, with encryption in transit and at rest. Patients are informed and consent just as they would with a human scribe or chaperone, and you review and sign every note before it enters the chart.
Then the note leaves it out. Medical Scribe only documents what was said or observed in the visit — it never fills in a menstrual history, exam finding, or diagnosis that did not actually come up.
Join thousands of healthcare professionals who save hours every day with Medical Scribe.