AI Medical Scribe for
Clinic days wedged between OR days leave no time for notes — yet every consult needs a documented exam, imaging discussion, and a risk conversation that may be read in court. Medical Scribe drafts it all from the visit itself.
A real example of the documentation Medical Scribe generates for neurosurgeons — ready before your patient leaves the room.
52F referred with 9 months of low back pain radiating down the right leg to the dorsum of the foot, worse with standing and walking, relieved by sitting. Completed 12 weeks of physical therapy and two epidural steroid injections with only transient relief. Numbness in right L5 distribution; denies bowel or bladder dysfunction, no saddle anesthesia. Current medications: naproxen 500mg twice daily, gabapentin 300mg three times daily. Non-smoker; works as a school administrator.
BP 124/78. Gait antalgic, heel-walk weak on right. Motor: right EHL 4/5, otherwise 5/5. Sensation reduced right L5 dermatome. Reflexes 2+ and symmetric; straight leg raise positive on right at 45 degrees. MRI lumbar spine (last month, reviewed with patient): grade 1 L4-L5 degenerative spondylolisthesis with severe central canal stenosis and right L5 lateral recess compromise.
Illustrative example. Every note is fully editable, and you control the format — SOAP, DAP, or your own custom template.
Thirty consults on your one clinic day, each needing history, neuro exam, imaging correlation, and surgical decision-making documented — before tomorrow's first case.
Neurosurgery carries outsized medicolegal exposure. What you said about risks, alternatives, and expected outcomes — and what the patient asked — must be in the record, accurately.
You walk patients through their MRI at the screen: the level, the grade, the compression. That discussion is clinically central and almost never makes it into the note verbatim.
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.
New spine and cranial consults, post-op wound checks, ward rounds, and telehealth follow-ups are all recorded and drafted the same way. Talk to the patient — history, exam findings narrated aloud, imaging walkthrough, surgical recommendation — and the note is waiting for review before you scrub for the next case.
Notes follow the built-in Neurosurgeon’s note template: Subjective, Objective with system-specific examination and imaging results, and a numbered Assessment & Plan covering diagnosis and rationale, planned procedure with expected outcomes and risks, pre-operative preparation, post-operative care, and referrals. A companion Neurology template handles non-operative visits.
Neurosurgeons are sued more than almost any specialty, and cases often turn on what the consent discussion contained. Medical Scribe documents the conversation that actually happened — risks named, alternatives offered, questions answered — and nothing it didn’t. You review, edit, and sign every note, so the chart is your account, verbatim in substance.
The note records the risks, alternatives, and expected outcomes you actually discussed, and the questions the patient asked — as they were said, never reconstructed or embellished. You review and sign before it enters the chart, so the record matches the conversation.
Yes. When you narrate the MRI or CT — level, grade of listhesis, degree of compression — that discussion lands in the Objective section of the note, with your interpretation attributed as stated. It never invents imaging findings.
Yes. The built-in Neurosurgeon's note template covers Subjective, Objective, and a per-issue Assessment & Plan including planned procedures, pre-operative preparation, and post-operative care — so a wound check produces a short note and a surgical consult produces a full one.
Medical Scribe records in-person and telehealth visits, with apps for iOS, Android, Web, Apple Watch, and Mac. It's HIPAA compliant and encrypted in transit and at rest, and free to get started.
Join thousands of healthcare professionals who save hours every day with Medical Scribe.