AI Medical Scribe for
Multimorbid patients deserve consult notes as thorough as your thinking — without you typing a 14-system review at 9pm. Medical Scribe drafts the full internist's note, from ROS to a numbered impression and plan, as the visit happens.
A real example of the documentation Medical Scribe generates for internal medicine specialists — ready before your patient leaves the room.
72M referred for unintentional weight loss — 6 kg over 3 months — with fatigue and early satiety. PMH: type 2 diabetes, atrial fibrillation, CKD stage 3a. Medications: metformin 1000mg BID, apixaban 5mg BID, metoprolol 50mg daily, atorvastatin 40mg daily. Ex-smoker, quit 2010; alcohol rare.
BP 128/74, HR 68 irregularly irregular, BMI 24.1 (down from 26.3). No lymphadenopathy or scleral icterus. Abdomen soft, no masses or organomegaly. Investigations: Hgb 11.2 (normocytic), HbA1c 6.8%, eGFR 52, TSH normal. CT abdomen/pelvis pending.
Illustrative example. Every note is fully editable, and you control the format — SOAP, DAP, or your own custom template.
A referred patient arrives with eight medications, five active problems, and a stack of outside results. The consult note has to reconcile all of it — history, ROS, exam, investigations, and reasoning per problem.
A proper multi-system ROS takes minutes to ask and nearly as long to type. Skipping it thins the note; typing it steals attention from a patient describing exactly the symptoms you need to hear.
The visits end at five; the documentation doesn't. Complex assessments written from memory hours later lose the pertinent negatives and reasoning that made the consult valuable.
The Internal Medicine Specialist's note ends in a numbered Impression & Plan — each issue with its own likely diagnosis, differentials, investigations, treatment, and referrals — so a patient with five active problems gets five documented plans, not one blended paragraph.
Constitutional through allergic/immunologic — the template's dedicated Review of Systems section captures the positives and pertinent negatives you elicit, in the systems you actually covered, without a single checkbox click.
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.
Internal medicine runs on synthesis: a referral question, a long history, outside results, and a differential built in real time. Medical Scribe records the encounter — new consult, follow-up, or telehealth — and drafts the complete Internal Medicine Specialist’s note while the reasoning is still fresh, instead of leaving it for a late-evening reconstruction.
The generated note mirrors the real template: Subjective with medications, allergies, and family and social history; a system-by-system Review of Systems; Objective split into Examination and Investigations; and a numbered Impression & Plan per problem. Doses, lab values, and pertinent negatives land where a reviewing colleague would look for them.
An internist’s note is read by referrers, hospitalists, and subspecialists who act on it. Medical Scribe documents only what was said and observed in the visit — it will not invent an exam finding, a lab value, or a differential — and every note passes through your review and signature before anyone else relies on it.
Yes. The Internal Medicine Specialist's note has a dedicated Review of Systems section spanning constitutional, cardiovascular, respiratory, GI, GU, neurological, psychiatric, endocrine, hematologic, and allergic/immunologic systems — populated with the positives and pertinent negatives actually elicited, never templated filler.
The note ends in a numbered Impression & Plan where each problem carries its own impression, differential, investigations, treatment, and referrals — mirroring how internists reason. It documents only the assessments and plans you actually stated during the visit.
Yes. A 60-minute new consult and a 15-minute follow-up each generate a note proportionate to the visit, in person or telehealth, on iOS, Android, Web, Apple Watch, or Mac. Beyond the internist's note, 280+ templates and custom formats are available.
Medical Scribe is HIPAA compliant, with recordings and notes encrypted in transit and at rest. You review, edit, and sign every note before it enters the chart, and it never invents clinical findings.
Join thousands of healthcare professionals who save hours every day with Medical Scribe.