AI Medical Scribe for
Your hands are gloved at the grossing bench and your findings are spoken out loud — then retyped later. Medical Scribe turns spoken findings, FNA clinic encounters, and patient-facing procedures into structured, review-ready documentation.
A real example of the documentation Medical Scribe generates for medical pathologists — ready as soon as you finish dictating.
47F referred for fine needle aspiration of a right thyroid nodule, 1.8 cm, TI-RADS 4 on recent ultrasound. No compressive symptoms, no prior neck irradiation, no family history of thyroid cancer. TSH 1.2 mIU/L. Procedure, risks, and alternatives explained; verbal and written consent obtained.
Ultrasound-guided FNA of the right mid-pole nodule following 1% lidocaine local anesthesia. Three passes performed with a 25-gauge needle. Patient tolerated the procedure well; pressure applied, no hematoma or immediate complications.
Rapid on-site evaluation of Diff-Quik-stained smears: specimen adequate, with multiple groups of follicular cells of at least 10 cells each across passes.
Preliminary: abundant colloid with benign-appearing follicular cells, favoring a benign follicular nodule. Final Bethesda categorization pending review of alcohol-fixed smears and cell block.
Final report to follow after full cytologic review. If benign on final review, surveillance ultrasound in 12-24 months was discussed with the patient and referring endocrinologist.
Illustrative example. Every note is fully editable, and you control the format — SOAP, DAP, or your own custom template.
Gross descriptions and procedure findings are voiced in the moment with gloved hands, then reconstructed or transcribed later — a delay that adds turnaround time to every case.
A pathologist-performed FNA needs a procedure note — indication, technique, passes, adequacy assessment, complications — documented alongside the specimen workflow, patient after patient.
Specimen dimensions, margin distances, and pass counts spoken aloud must reach the record exactly. A transposed measurement in a report is a defensibility problem, not a typo.
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.
Not all pathology is silent microscopy. FNA clinics, on-site adequacy assessments, grossing narration, and consults with treating clinicians are spoken work. Medical Scribe records what you say — at the bench, in the procedure room, or over telehealth with a referring physician — and drafts structured documentation from it.
A draft organizes your narration into the sections your workflow needs — clinical history, procedure, adequacy assessment, impression, and follow-up for an FNA encounter, or your own custom gross-description format. Measurements, pass counts, and stain references appear as you stated them, ready for your review rather than your retyping.
A pathology record is only trustworthy if every value in it was actually observed. Medical Scribe never invents findings, measurements, or diagnoses — it documents your spoken words and leaves interpretation where it belongs, with you. Each note stays a draft until you verify it against the case and sign.
Instead of a verbatim transcript to edit, you get a structured draft: what you said at the bench or in clinic is organized into your note's sections, with only your spoken findings included — never inferred ones. You review and sign as always.
Yes. An FNA clinic encounter — consent, technique, passes, on-site adequacy assessment, preliminary impression — is a recorded conversation and procedure narration, and the draft note reflects exactly what you stated during it.
Custom templates take minutes, so you can mirror your lab's gross description format, synoptic style, or autopsy structure. SOAP, DAP, and fully custom formats are supported alongside 280+ built-in specialty templates.
Medical Scribe is HIPAA compliant with encryption in transit and at rest. Recordings are processed securely, and nothing becomes part of the record until you have reviewed and signed it.
Join thousands of healthcare professionals who save hours every day with Medical Scribe.