AI Medical Scribe for
You don't chart visits — you dictate cases: gross descriptions at the bench, microscopic findings at the scope, intraoperative consults under the clock. Medical Scribe turns that spoken dictation into a structured report draft you review and sign out.
A real example of the documentation Medical Scribe generates for neuropathologists — ready as soon as you finish dictating.
54M with 6 weeks of progressive word-finding difficulty and one witnessed focal seizure. MRI: 4.2 cm ring-enhancing left temporal mass with surrounding edema. Left temporal craniotomy with resection; intraoperative consultation requested.
Smear and frozen section, left temporal mass: hypercellular glial neoplasm with marked atypia and necrosis — consistent with high-grade glioma. Communicated to Dr. Reyes in OR 4 at 10:42.
Received fresh, labeled 'left temporal tumor': multiple tan-gray soft tissue fragments aggregating 3.5 x 3.0 x 1.2 cm with focal hemorrhage and yellow-tan necrotic areas. Representative sections submitted in cassettes A1-A5; tissue allocated for molecular studies.
Sections show a diffusely infiltrating astrocytic neoplasm with marked nuclear pleomorphism, brisk mitotic activity, microvascular proliferation, and palisading necrosis. Immunohistochemistry: GFAP positive, IDH1 R132H negative, ATRX retained, p53 patchy; Ki-67 approximately 30%.
Left temporal mass, resection: glioblastoma, IDH-wildtype (CNS WHO grade 4) — pending confirmatory molecular studies; addendum to follow with methylation and MGMT promoter status.
Illustrative example. Every note is fully editable, and you control the format — SOAP, DAP, or your own custom template.
An intraoperative consult means a diagnosis to the OR in about 20 minutes — and a faithful record of what you saw and what you told the surgeon, written while the next case waits.
Clinical history, gross description, microscopic description, immunostains, integrated diagnosis, comment — every case demands the same structure, and transcription backlogs delay sign-out.
Oncologists, surgeons, and tumor boards act on your report verbatim. A dropped 'not' or a garbled marker name in transcription is a patient-safety 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.
Neuropathology is spoken work: describing fragments at the grossing station, narrating fields at the microscope, calling a frozen to the OR. Medical Scribe records that dictation on whatever device is at hand — including hands-free from an Apple Watch while your gloves are on — and drafts the structured report while the case is still in front of you.
Build a custom template in minutes matching your sign-out structure — clinical history, intraoperative consultation, gross description, microscopic description, immunohistochemistry, and integrated diagnosis with comment — and every dictation drops into it. Addenda for pending molecular studies work the same way. SOAP-style clinic formats are there too, for the rare patient-facing consult.
A pathology report is the diagnosis of record, and downstream treatment turns on its exact wording. Medical Scribe documents only what you dictated — it will not invent a stain result, a measurement, or a margin — and no report is finalized until you have reviewed, edited, and signed it out yourself.
Yes — that's the honest fit. Medical Scribe records what you say at the grossing bench, the cryostat, or the multiheaded scope and drafts a structured report from it. It documents only what you actually dictated; it never adds findings, measurements, or markers you didn't state.
You can build a custom template in minutes that mirrors your report format — clinical history, intraoperative consultation, gross description, microscopic description with immunostains, and diagnosis with comment — and reuse it case after case. There are 280+ built-in specialty templates to start from.
The draft is generated from your actual dictation, including antibody names, molecular markers, and grading terminology. Every report passes through your review and edit before sign-out, so nothing enters the record without your eyes on it.
Yes. Medical Scribe is HIPAA compliant, with recordings and drafts encrypted in transit and at rest. It runs on iOS, Android, Web, Apple Watch, and Mac — so the same tool works at the bench, at the scope, and at brain cutting.
Join thousands of healthcare professionals who save hours every day with Medical Scribe.