AI Medical Scribe for
Every work injury visit ends in paperwork — a clinical note, a work capacity certificate, a return-to-work plan. Medical Scribe drafts the clinical note from the visit conversation, so the rest of the paperwork has something solid to stand on.
A real example of the documentation Medical Scribe generates for occupational medicine specialists — ready before your patient leaves the room.
42M warehouse picker presenting with acute right-sided lower back pain after lifting a 25 kg carton two days ago. Pain immediate at time of lift, no radiation below the knee, no numbness or weakness. No prior back injuries or claims. Taking ibuprofen 400mg PRN with partial relief. Non-smoker, otherwise well.
Gait normal, transfers independently. Lumbar flexion limited to 40 degrees by pain, extension 15 degrees. Tenderness over right paraspinal muscles, no midline tenderness. Straight leg raise negative bilaterally. Lower limb power 5/5, reflexes symmetric, sensation intact.
Illustrative example. Every note is fully editable, and you control the format — SOAP, DAP, or your own custom template.
Causation, work-relatedness, and capacity statements can end up quoted in a workers' compensation dispute years later. Thin or ambiguous notes become a liability for you and your patient.
A single injury assessment feeds the clinical note, the work status certificate, the employer communication, and the return-to-work plan — all drawing on the same history and exam you only want to capture once.
Pre-placement exams, injury assessments, and periodic reviews stack up fast, and comp schemes expect certificates and reports on fixed timelines — not when you catch up on charting.
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.
Whether it’s an acute injury assessment, a fitness-for-duty evaluation, or a periodic surveillance exam, Medical Scribe records the visit — in person or telehealth — and drafts the note while you focus on the worker in front of you. Restrictions, timelines, and the return-to-work conversation are captured as you discuss them, not reconstructed at day’s end.
The generated note follows the Occupational Medicine Specialist’s note template: Subjective history including mechanism of injury, a structured Review of Systems, Objective examination and investigation findings, and an Impression & Plan organized issue by issue — diagnosis, planned investigations, treatment, and referrals for each problem.
In occupational medicine, the note is evidence. Medical Scribe documents only what was said and observed in the visit — it never fabricates findings or causation opinions — so when a claim is contested, your record reflects exactly what you assessed and advised, in your own words.
The Occupational Medicine Specialist's note captures the mechanism of injury, examination findings, work-relatedness discussion, and specific duty restrictions exactly as covered in the visit — the clinical foundation your work capacity certificates and insurer reports are built on. You review and sign before anything goes in the chart.
No. Medical Scribe only documents what was actually said and observed during the visit — it never invents clinical findings or opinions. If you state that the mechanism is consistent with the reported lift, that is what appears; if you don't address causation, the note won't either.
Yes. The built-in template includes a full review of systems for structured screening visits, and you can build custom templates in minutes to match your recurring exam formats. Medical Scribe ships with 280+ specialty templates, including the Occupational Medicine Specialist's note.
Medical Scribe is HIPAA compliant, with encryption in transit and at rest. Recordings are processed securely, and nothing enters the record until you have reviewed and signed the note yourself.
Join thousands of healthcare professionals who save hours every day with Medical Scribe.