AI Medical Scribe for
Behavioral health sessions are pure conversation — and the note still needs an MSE, risk assessment, and DSM-5-anchored diagnosis. Medical Scribe drafts the structured note from the session so you can keep your attention where the work happens.
A real example of the documentation Medical Scribe generates for mental health and behavioral specialists — ready before your patient leaves the room.
26F attending 4-week follow-up for generalized anxiety disorder with panic attacks. Reports two panic episodes since last session, down from near-daily, both at work; used paced breathing with partial success. Sleep improved to 6-7 hours. GAD-7 today: 11, down from 16 at intake.
Denies suicidal or homicidal ideation, intent, or plan. No self-harm since intake. Protective factors: supportive partner, consistent attendance, engaged in skill practice between sessions.
Generalized anxiety disorder (F41.1) with panic attacks, improving on current treatment plan.
Illustrative example. Every note is fully editable, and you control the format — SOAP, DAP, or your own custom template.
Behavioral work depends on tracking affect, engagement, and what's left unsaid. A keyboard between you and the client undermines the observation your MSE relies on.
Care plans, insurers, and supervising clinicians expect MSE findings, risk assessment, DSM-5-supported diagnosis, and measurable treatment goals — not a paragraph of session recap.
A day of 50-minute sessions with 10-minute gaps means documentation stacks up — and safety-relevant details written hours later are the ones most likely to blur.
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 weekly CBT session, an intake, or a telehealth check-in, Medical Scribe records the conversation and drafts a complete behavioral health note — presenting complaints, history, MSE, risk, diagnosis, and plan. Your eyes stay on the client; the structure is waiting when the session ends.
Drafts follow the built-in Mental Health and Behavioural Specialist’s note: History of Presenting Complaints, Past Medical & Psychiatric History, Medications, Family and Social History, Mental Status Examination, Risk Assessment, Diagnosis, Treatment Plan, and Safety Plan — with DSM-5 criteria and outcome measures recorded where you stated them.
When a client discloses ideation or a safety plan changes, the note has to reflect precisely what was said — not a paraphrase from memory at 9 PM. Medical Scribe documents the session’s actual language in the Risk Assessment and Safety Plan sections, giving your clinical decisions a record that stands up to scrutiny.
Yes. The Mental Health and Behavioural Specialist's note template includes dedicated Mental Status Examination, Risk Assessment, and Safety Plan sections, populated only from what was said and observed in the session — it never invents clinical findings.
Medical Scribe drafts the progress note — the record that goes in the chart. Your private psychotherapy notes remain yours. DAP and SOAP formats are supported alongside the full behavioral template, and a Mental Health Care Plan template is also built in.
The same way they would to any scribe or trainee: you inform them and obtain consent. Many clinicians cover it in intake paperwork. Recordings are HIPAA compliant and encrypted in transit and at rest, and you control what is retained.
Notes capture symptom measures like the GAD-7, functional impact, interventions used, and progress against treatment goals — the substance reviewers look for. You review and sign every note before it enters the record.
Join thousands of healthcare professionals who save hours every day with Medical Scribe.