AI Medical Scribe for
Rounding on a full NICU census means a daily progress note for every baby — plus family meetings that deserve careful documentation. Medical Scribe drafts both from the conversations you're already having.
A real example of the documentation Medical Scribe generates for neonatologists — ready before your patient leaves the room.
Baby boy R, ex-26+4 weeks, day of life 34 (31+3 corrected). Overnight team reports two brief self-resolving bradycardic episodes with feeds. Mother visited yesterday evening, did kangaroo care, and asked about progress toward coming off CPAP. No new concerns from the bedside nurse this morning.
Weight 1420g, up 22g. HR 148, RR 52, temp 36.9C. On CPAP 5 cmH2O, FiO2 23%. Feeds at 28 mL fortified expressed breast milk q3h via NG, tolerated with minimal aspirates. On caffeine citrate 10 mg/kg/day. Exam: soft anterior fontanelle, clear breath sounds with mild subcostal retractions, soft abdomen, warm and well-perfused. Yesterday's hemoglobin 10.4 g/dL.
Ex-26-week infant with resolving respiratory distress on low CPAP support and appropriate growth trajectory. Bradycardic episodes with feeds consistent with prematurity, stable on caffeine. Anemia of prematurity, currently asymptomatic.
Illustrative example. Every note is fully editable, and you control the format — SOAP, DAP, or your own custom template.
Daily notes on every infant — respiratory support, feeds, growth, labs, active problems — consume hours after rounds, and each one has to stand alone for the covering team.
Antenatal counseling at the edge of viability, care conferences, and consent discussions are among the most consequential conversations in medicine — and among the hardest to document faithfully from memory.
A 2am delivery means a full admission note — maternal history, delivery course, resuscitation, exam, and plan — written while you're stabilizing the patient.
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.
Present the baby the way you already do — overnight events, support settings, feeds, growth, exam, plan — and Medical Scribe drafts the daily progress note from it. Family updates at the bedside and formal care conferences are captured the same way, whether in person or by telehealth. Apps for iOS, Android, Web, Apple Watch, and Mac.
Generated notes follow the built-in Neonatologist’s note template — Subjective, Objective, Assessment, Plan — capturing history of present illness, growth and nutrition detail, system-by-system exam findings, and a plan covering investigations, treatments with doses, referrals, and follow-up. Need your unit’s admission or systems-based format instead? Custom templates take minutes.
When you counsel parents at 23 weeks or discuss withdrawing support, what was said matters for years. Medical Scribe documents the actual conversation — the risks explained, the questions asked, the decisions reached — without inventing a word. You review and sign, so the record reflects exactly the discussion that happened.
Yes. Antenatal consults, care conferences, and consent discussions are recorded conversations like any visit — the note reflects what was actually discussed, including questions the family asked and the plan agreed. You review and sign before it enters the chart.
The note is generated from what's said, so corrected age, CPAP settings, FiO2, feed volumes, and mg/kg dosing appear as you stated them on rounds. The built-in Neonatologist's note template structures it into Subjective, Objective, Assessment, and Plan. Medical Scribe never invents values that weren't mentioned.
Recording consent works like any scribe or trainee present at the bedside: inform the parents or guardians per your unit's policy. Medical Scribe is HIPAA compliant and encrypted in transit and at rest.
Yes. Start from the Neonatologist's note template or build a custom template in minutes to mirror your unit's daily progress note or admission note structure, including systems-based formats.
Join thousands of healthcare professionals who save hours every day with Medical Scribe.