AI Medical Scribe for
Between touch-time cares, parent updates, and handoff, NICU charting piles up fast. Medical Scribe turns your spoken assessments and family conversations into structured nursing notes you review and sign.
A real example of the documentation Medical Scribe generates for neonatal nurses — ready before your patient leaves the room.
Baby girl M, born 29+2, now day of life 27 (33+1 corrected). Level III NICU, bed 12. Assessment 0800.
Mother at bedside for morning cares; reports baby seemed more settled overnight per night team. Asked about timeline for moving from feeding tube to full bottle feeds and about kangaroo care today. No new family concerns.
HR 152, RR 48, temp 36.8C axillary, SpO2 95% on high-flow nasal cannula 2L, FiO2 21%. Weight 1840g, up 25g. Tolerating 34 mL fortified expressed breast milk q3h via NG tube; took 15 mL of one feed by bottle with coordinated suck-swallow-breathe. Abdomen soft, minimal aspirates, voiding and stooling normal. Skin intact; NG tape site clean.
Stable ex-29-week infant progressing on oral feeding; respiratory status stable on low-flow support; appropriate weight gain; family engaged in cares.
Continue one bottle attempt per shift as tolerated, advancing per cue-based feeding protocol. Reassess high-flow weaning with team on rounds. Next weight tomorrow. Continue parent teaching toward discharge readiness.
Illustrative example. Every note is fully editable, and you control the format — SOAP, DAP, or your own custom template.
Every touch time generates documentation — vitals, feeds, output, skin checks, line sites. Multiply by two or three high-acuity babies and the end-of-shift backlog is real.
Updates at the bedside, discharge teaching, and worried questions at 2am all matter clinically — but they're the first thing to go undocumented when the shift gets busy.
The next shift inherits your assessment. Thin notes on feeding tolerance, respiratory support changes, or family concerns create risk for a patient who can't speak for themselves.
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.
NICU nursing happens in clustered bursts — assessment, feed, cares, parent update — with charting squeezed in between. Medical Scribe records what you say and discuss during those moments, including bedside conversations with parents, and drafts the structured note so the end of shift isn’t a documentation sprint. Apple Watch support keeps it hands-free at the isolette.
Notes follow the built-in Neonatal Nurse’s note template: Patient Information, Subjective, Objective, Assessment, Plan, Interventions, Evaluation, and Plan for Continuing Care. Feeding tolerance, respiratory support settings, skin and line checks, and family teaching all land in sections the next shift can actually use.
Neonates can’t report their own history — the chart is it. Medical Scribe documents only what was said and observed, never inventing vitals, feeds, or exam findings, and you review and sign before anything is filed. The result is a defensible, continuous record across shifts for patients with zero margin for error.
Yes. The built-in Neonatal Nurse's note template includes Patient Information, Subjective, Objective, Assessment, Plan, Interventions, Evaluation, and Plan for Continuing Care — so your interventions, the infant's response, and handoff-relevant next steps each have their own section.
The note is built from what is spoken and observed aloud — your verbalized assessment during cares, parent conversations, and updates at the bedside. Many nurses narrate briefly ('abdomen soft, minimal aspirate, site clean') and the note structures it. It never invents findings.
Yes. Discharge teaching, feeding-cue education, and family questions discussed at the bedside are documented in the relevant sections, giving you a record that the conversation happened and what was covered.
Medical Scribe is HIPAA compliant and encrypted in transit and at rest. You review and sign every note before it goes into the chart, and it runs on iOS, Android, Web, Apple Watch, and Mac — including hands-free capture from the Watch during cares.
Join thousands of healthcare professionals who save hours every day with Medical Scribe.