AI Medical Scribe for
Hepatology nutrition consults run deep — diet recalls, sodium and protein targets, sarcopenia screening — with an ADIME note to match. Medical Scribe drafts your Assessment through Monitoring while you counsel the patient.
A real example of the documentation Medical Scribe generates for liver dietitians — ready before your patient leaves the room.
Inadequate protein-energy intake related to early satiety from ascites and prolonged overnight fasting, as evidenced by intake at 0.8 g/kg protein, muscle wasting, and 13-hour overnight fast (PES).
Review in 3 weeks: repeat mid-arm circumference and handgrip strength, weight and ascites status with hepatology, adherence to snack and sodium targets. Escalate to hepatology dietitian MDT if intake remains below prescription.
Illustrative example. Every note is fully editable, and you control the format — SOAP, DAP, or your own custom template.
Anthropometrics, biochemistry, nutrition-focused physical findings, and a defensible PES statement — every liver consult demands the full nutrition care process on paper.
Protein at 1.2-1.5 g/kg, sodium under 2 g, fluid limits with hyponatremia — in decompensated cirrhosis, the difference between what you advised and what got charted matters clinically.
A 24-hour recall, food preferences, ascites-related early satiety, and alcohol history don't fit a 10-minute chat — and reconstructing that detail later means losing half of it.
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.
Whether it’s a new decompensated cirrhosis referral on the ward, a MASLD clinic visit, or a pre-transplant nutrition workup by telehealth, Medical Scribe records the consult and drafts the note while you finish the counseling. The hour you spend on the diet history stops costing a second hour of typing.
The built-in Liver Dietitian’s note template structures every consult into Assessment (history, anthropometrics, biochemistry, dietary recall, physical findings), Diagnosis with PES statement, Intervention (your nutrition prescription, education, and counseling), and Monitoring and Evaluation. It’s the nutrition care process you already follow — written for you, reviewed by you.
In hepatic encephalopathy, ascites, and sarcopenia, the numbers are the treatment: grams of protein, grams of sodium, hours of overnight fast. Medical Scribe records the targets you actually set — never inventing or rounding them — so the chart says exactly what you prescribed.
Yes. The Liver Dietitian's note template follows the nutrition care process — Assessment, Diagnosis, Intervention, Monitoring and Evaluation — and captures your PES statement as you formulate it aloud. It only includes a PES if you actually stated one.
The anthropometric, biochemical, and dietary data you discuss are filed in Assessment exactly as stated — including distinctions like fluid weight versus estimated dry weight. Nothing is calculated or invented on your behalf.
Yes. Record bedside consults, clinic visits, or telehealth follow-ups on iOS, Android, Web, Apple Watch, or Mac. Each recording becomes a draft note you review, edit, and sign.
Medical Scribe is HIPAA compliant and encrypted in transit and at rest. Recordings are processed securely and nothing enters the record without your review.
Join thousands of healthcare professionals who save hours every day with Medical Scribe.