AI Medical Scribe for
Ventilator settings, vasopressor doses, family meetings about goals of care — ICU documentation is dense and constant. AI drafts your admission notes, daily reviews, and family discussions from the conversation at the bedside.
A real example of the documentation Medical Scribe generates for intensive care specialists — ready before your patient leaves the room.
61M admitted from ED with community-acquired pneumonia and septic shock. Three days of productive cough, fevers, and progressive dyspnea; found hypotensive and hypoxic in ED. PMH: COPD (home tiotropium), hypertension on amlodipine 5mg, 30 pack-year smoking history, quit 5 years ago. NKDA. History from wife: independent at baseline, walks daily, no prior ICU admissions. No advance care directive; wife is next of kin.
Intubated and sedated post ED, RASS -3 on propofol. Norepinephrine 0.12 mcg/kg/min for MAP >65. Ventilated SIMV: TV 420mL (6 mL/kg IBW), RR 22, PEEP 10, FiO2 0.6. Coarse crackles right base. Warm peripheries, cap refill 3s. Urine output 25 mL/h since arrival. Abdomen soft; no rash; pupils equal and reactive.
1. Severe CAP with septic shock — ceftriaxone 1g IV daily plus azithromycin 500mg IV daily; cultures pending, de-escalate on sensitivities. Norepinephrine titrated to MAP >65; reassess volume state 4-hourly. 2. Hypoxic respiratory failure — lung-protective ventilation, target plateau pressure <30, daily sedation interruption and SBT assessment once shock resolving. 3. Acute kidney injury — likely pre-renal; monitor output hourly, avoid nephrotoxins. 4. Family — wife updated at bedside on diagnosis, supports, and 48-hour outlook; formal family meeting planned for tomorrow; resuscitation status: full treatment, to be revisited.
Illustrative example. Every note is fully editable, and you control the format — SOAP, DAP, or your own custom template.
A single ICU patient means ventilation, hemodynamics, sedation, renal, infection, nutrition, and lines — each with numbers that change by the hour and all of it expected in today's note.
Family meetings about prognosis, treatment limitations, and resuscitation status carry enormous clinical and legal weight. A two-line summary of an hour-long discussion is a liability.
When a patient deteriorates, notes wait. Then the retrieval call comes, the next admission arrives, and yesterday's charting is still open at 11pm.
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.
ICU documentation happens between crises: admissions at 2am, a deterioration mid-round, a family arriving unannounced. Medical Scribe records your spoken assessment at the bedside — admission, daily review, or family meeting — and drafts the note immediately, so documentation stops being the task that waits until the unit is quiet.
The built-in Intensive Care Specialist’s note structures the encounter into Subjective and Review of Systems, an Objective section split into Examination and Investigations — ventilation parameters, vasopressor doses, gases, imaging — and an issue-numbered Impression & Plan, so respiratory failure, shock, AKI, and family communication each get their own explicit assessment and plan.
ICU notes get scrutinized — at morbidity meetings, in coronial reviews, by families’ lawyers. Medical Scribe documents only what was actually said and observed at the bedside: the settings you stated, the prognosis you explained, the limits the family agreed to. The record reflects your care as it happened, not as it was remembered.
Yes — record the meeting like any encounter and the note captures what was actually discussed: prognosis explained, questions asked, decisions on treatment limits and resuscitation status. Nothing is paraphrased into existence; you review and sign before it enters the record.
The values you speak on the ward round — PEEP, FiO2, tidal volume, norepinephrine in mcg/kg/min — are transcribed as stated into the Intensive Care Specialist's note. It never invents numbers, and you verify the draft before signing.
Intensivists typically record their spoken summary at each bed — the same synthesis you'd dictate anyway — on iOS, Android, or Apple Watch. Each patient's round entry becomes its own structured note, drafted before you reach the next bed.
Medical Scribe is HIPAA compliant with encryption in transit and at rest. Notes are editable drafts until you sign them, and the built-in template library (280+ specialties) includes the Intensive Care Specialist's note plus custom formats for your unit's daily review structure.
Join thousands of healthcare professionals who save hours every day with Medical Scribe.