HIPAA Compliant
AI Medical Scribe for
Nursing Assistants
Between vitals rounds, turns, and call bells, CNA charting gets squeezed into whatever minutes are left. Dictate as you go and Medical Scribe drafts the shift note for you.
Sample note
What your notes will look like
A real example of the documentation Medical Scribe generates for nursing assistants — ready before your patient leaves the room.
Subjective
71M, day 4 post-stroke on the rehab unit. Speech remains slurred but understandable. Asked for extra help cutting food at lunch; expressed frustration with left hand weakness.
Objective
- 0800 vitals: BP 142/88, HR 78, Temp 37.1°C, SpO2 97% on room air
- Repositioned q2h per turn schedule; heels floated on pillow
- Breakfast 100% with setup assistance; fluids approximately 1200ml by 1500
- Voided x3; no incontinence episodes this shift
Assessment
Left-sided weakness unchanged from yesterday. Mood lower — frustration voiced during lunch.
Interventions
- Meal tray set up with adaptive utensils; supervised during eating
- Assisted with partial bed bath and oral care
- Notified RN of low mood and feeding difficulty at 1520
Evaluation
Skin intact at all pressure points on final check. Patient resting comfortably at handoff; RN aware of mood change.
Illustrative example. Every note is fully editable, and you control the format — SOAP, DAP, or your own custom template.
Charting squeezed between call bells
More patients than hours
Assignments of eight, ten, twelve patients — each needing vitals, intake and output, and care activities logged before handoff. The math never works in your favor.
Rounds and turns on repeat
Q4h vitals, q2h repositioning, I&O totals — the entries are small but relentless, and missing one looks like missed care even when the care happened.
Your notes protect patients and you
Skin checks, falls, and refusals of care are exactly what incident investigations and facility surveys pull first. A thin entry leaves you defending memory against paper.
AI-Powered Documentation
Real-time transcription that understands medical terminology and clinical context.
Specialty Vocabulary
Recognizes terms, conditions, and procedures specific to your practice area.
Save Hours Daily
Generate comprehensive clinical notes in minutes instead of hours.
HIPAA Compliant
Enterprise-grade encryption and security to protect sensitive data.
Built-in templates
Note templates built for nursing assistants
These aren't generic formats — they ship in the product today, structured around how you actually document.
Nursing Auxiliary's note
Patient Information
Subjective
Objective
Assessment
Plan
Interventions
Plus 280+ templates across every specialty — or build your own in minutes.
Built around rounds, not desks
CNA work happens in two-minute bursts — a turn here, a vitals check there, a call bell in between. Medical Scribe fits the same rhythm: dictate what you did as you leave each room, and the shift note assembles itself. By handoff, your documentation is drafted instead of owed, whether you’re on a hospital unit or in a skilled nursing facility.
What the Nursing Auxiliary’s note captures
The generated note follows the built-in Nursing Auxiliary’s note template: Patient Information, Subjective, Objective, Assessment, Plan, Interventions, Evaluation, and Plan for Continuing Care. Turn schedules kept, intake and output, mobility assistance, and every escalation to the RN are structured into their sections — so nothing you did disappears into a rushed one-liner.
When the survey team pulls your notes
Falls, pressure injuries, and refusals of care are judged on what was documented at the time. Because Medical Scribe drafts from the actual encounter — never inventing an observation you didn’t voice — your entries show the q2h turns you really did and the changes you really reported. You sign every note, so the record is yours and accurate.
Frequently asked questions
Is there a note format made for nursing assistants?
Yes. The built-in Nursing Auxiliary's note template covers the ground CNAs document — Subjective and Objective observations, Assessment, Interventions like repositioning and hygiene care, Evaluation, and Plan for Continuing Care — among 280+ specialty templates.
Can I dictate right after a round instead of typing at the station?
Yes. Speak a quick summary on your phone or Apple Watch as you leave the room — vitals, intake, what you did, what you reported — and Medical Scribe drafts the structured entry. Apps run on iOS, Android, Web, Apple Watch, and Mac.
What if I only mention some vitals — will it fill in the rest?
No. It documents only what you actually said or observed and never invents numbers, care activities, or patient responses. Anything missing stays missing until you add it — and you approve every note before it's filed.
Is this okay to use with patient information?
Yes. Medical Scribe is HIPAA compliant, encrypted in transit and at rest, and you review each note before it enters the record. It supports 57 languages for multilingual teams and patients.
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