AI Medical Scribe for
Every session ends with an MSE, a risk assessment, and a treatment plan to write — often with medications to track too. Medical Scribe drafts the full note from the session itself, so your evenings stay yours.
A real example of the documentation Medical Scribe generates for nurse psychotherapists — ready before your patient leaves the room.
41F — session 6 for generalized anxiety disorder. Reports fewer catastrophic thoughts at work since starting thought records. GAD-7 today 8, down from 14 at intake. Sleeping 6-7 hours; still avoiding highway driving.
Denies suicidal or homicidal ideation, intent, or plan. No self-harm since intake. Protective factors: engaged in therapy, supportive partner, stable employment.
Illustrative example. Every note is fully editable, and you control the format — SOAP, DAP, or your own custom template.
You can't track affect, speech, and thought process while typing. Clients read the screen-glance as distraction, and the therapeutic work suffers for it.
Suicidal ideation screening, safety planning, and protective factors must be recorded precisely every session — a vague risk entry is both a clinical gap and a professional liability.
Fifty-minute hours with no gaps mean MSEs get reconstructed hours later, when the details of who said what have already blurred together.
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.
Nurse psychotherapists blend nursing assessment with sustained therapeutic work, and the chart has to show both. Medical Scribe records the session — in the office or over telehealth — and drafts a complete note covering presenting complaints, medication status, mental status examination, risk, and the psychotherapy plan. You review, edit, and sign between clients instead of after hours.
The generated note follows the built-in Nurse Psychotherapist’s note template: History of Presenting Complaints, Past Medical & Psychiatric History, Medications, Family History, Social History, Mental Status Examination, Risk Assessment, Diagnosis, Treatment Plan, and Safety Plan. A Mental Health Care Plan template is also built in for referral-based care arrangements.
When a client’s risk status is questioned later, the record of what they said — ideation, intent, plan, protective factors — is what you’ll rely on. Because the note is drawn from the session itself rather than end-of-day memory, and because nothing is ever invented, your Risk Assessment and Safety Plan sections say exactly what happened in the room.
Yes. The built-in Nurse Psychotherapist's note template has dedicated Mental Status Examination, Risk Assessment, and Safety Plan sections — populated only from what was actually said and observed in the session. It never invents a clinical finding.
You stay in control. The generated note is a fully editable draft, so you decide what level of session detail enters the clinical record before you sign — and anything you'd rather keep as separate process notes simply doesn't go in.
The same way they would to any scribe or trainee: you inform them and ask. Medical Scribe is HIPAA compliant with encryption in transit and at rest, and many clinicians find clients accept it readily once they see the clinician more present.
Yes. The template includes a Medications section, so doses, adherence, and side effects discussed in session are captured for coordination with the prescriber — alongside diagnosis, DSM-5-informed formulation, and the psychotherapy plan.
Join thousands of healthcare professionals who save hours every day with Medical Scribe.