AI Medical Scribe for
Chemo side effects change what your patients can eat week to week — and every contact needs a full ADIME note. Medical Scribe drafts the Assessment, Diagnosis, Intervention, and Monitoring sections from the counseling conversation you were going to have anyway.
A real example of the documentation Medical Scribe generates for oncology dietitians — ready before your patient leaves the room.
64M with stage IVa oropharyngeal SCC, week 4 of 7 of chemoradiation. Weight 71.2 kg, down 3.1 kg (4.2%) over 4 weeks; BMI 23.4. Reports odynophagia and taste changes; estimated intake ~50% of needs. Managing 3 oral nutrition supplements daily. Grade 2 mucositis per radiation oncology. Lives with wife, who prepares meals.
Inadequate oral intake related to treatment-associated odynophagia and dysgeusia, as evidenced by 4.2% weight loss in 4 weeks and intake approximately 50% of estimated needs. Consistent with moderate malnutrition in the context of chemoradiation.
Illustrative example. Every note is fully editable, and you control the format — SOAP, DAP, or your own custom template.
Patients on chemoradiation need frequent nutrition monitoring, and each contact — clinic, infusion suite, or phone — requires a complete note with updated weights, intake, and symptoms.
Problem, etiology, signs and symptoms have to line up cleanly with your assessment data. Reconstructing that structure hours after the visit is where precision gets lost.
Percent weight loss, intake versus estimated needs, muscle wasting — if it isn't documented clearly, the care team and the record understate real nutritional risk.
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.
An oncology nutrition visit is mostly conversation — symptom review, intake recall, education, and problem-solving around mucositis or dysgeusia. Medical Scribe records that conversation, in the clinic, at the infusion chair, or over telehealth, and drafts your ADIME note so counseling time doesn’t become charting time.
The Oncology Dietitian’s note maps to the nutrition care process: Assessment collects anthropometrics, labs, nutrition-focused physical findings, and dietary history; Diagnosis holds the problem and PES statement; Intervention documents the prescription, supplementation, education, and care coordination; Monitoring and Evaluation records progress tracking and the follow-up plan.
Percent weight loss and intake estimates trigger real decisions — feeding tube discussions, treatment breaks, dietitian escalation. Medical Scribe documents only the values and findings actually stated in the visit, never inventing data, so the nutritional risk in the chart is the risk you assessed.
Yes. The Oncology Dietitian's note follows Assessment, Diagnosis, Intervention, and Monitoring and Evaluation — anthropometrics, biochemical data, nutrition-focused physical findings, and dietary history are organized where they belong.
It captures the PES statement and nutrition diagnosis you articulate during the visit — it never invents a diagnosis or fabricates assessment data. Everything in the draft comes from what was actually said, and you review before signing.
Yes. Medical Scribe records in-person and telehealth visits, with apps for iOS, Android, Web, Apple Watch, and Mac — so bedside consults in the chemo chair and follow-up video calls both generate notes.
Medical Scribe is HIPAA compliant, encrypted in transit and at rest. Notes are editable drafts until you review and sign them, and it works in 57 languages for counseling diverse patient populations.
Join thousands of healthcare professionals who save hours every day with Medical Scribe.