AI Medical Scribe for
You already speak your slit lamp and fundus findings out loud — why type them again? Medical Scribe drafts the note as you examine, so a 40-patient clinic day doesn't end with 40 unfinished charts.
A real example of the documentation Medical Scribe generates for ophthalmologists — ready before your patient leaves the room.
72M with primary open-angle glaucoma OU, on latanoprost 0.005% nightly for 3 years. No eye pain, redness, or subjective vision change. Admits to occasional missed doses on weekends. Hypertension controlled on amlodipine 5mg; no new systemic medications.
POAG OU — right eye stable at target pressure; left eye above target with progressive inferotemporal RNFL thinning, likely compounded by weekend non-adherence.
Illustrative example. Every note is fully editable, and you control the format — SOAP, DAP, or your own custom template.
Post-ops, injections, glaucoma checks, new referrals — 40 or more encounters a day means even two minutes of typing per chart adds up to hours of documentation.
You verbalize the exam at the slit lamp — acuity, pressures, segments, cup-to-disc — and then someone has to key every value into the note. That someone is usually you, after clinic.
Glaucoma and retina patients return for years. Each visit needs consistent structure so pressure trends, OCT changes, and treatment responses stay readable across dozens of encounters.
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.
Dilated exams, post-op day-ones, pressure checks, injection visits — Medical Scribe records each encounter and drafts the note while you move to the next lane. Speak your findings at the slit lamp as you normally would; the draft is built from the visit itself, not from your memory of it at 6 p.m.
The Ophthalmologist’s note organizes the visit into Subjective history — complaint, past ocular history, medications — and an Objective section with visual acuity, intraocular pressure, anterior and posterior segment findings, and additional tests like OCT and fields, followed by Assessment with differentials and a Plan covering treatment, follow-up, education, and referrals.
A treatment change can turn on 3 mmHg or a few microns of RNFL. Medical Scribe documents only the values and findings you actually stated during the exam — it never fabricates or fills in numbers — so the chart carries your measurements, exactly.
Laterality, pressures, acuities, and segment findings are captured as you dictate them during the exam and placed in the Objective section of the Ophthalmologist's note. You verify the draft before signing — and it never invents a value you didn't say.
Brief procedural encounters generate appropriately brief notes, and you can build a custom template in minutes for your intravitreal injection or laser routine — alongside the 280+ built-in templates, including the Ophthalmologist's note.
Every note follows the same structure — Subjective, Objective with VA, IOP, anterior and posterior segment and imaging, Assessment, and Plan — so serial glaucoma or retina visits read consistently and trends are easy to trace.
Medical Scribe is HIPAA compliant with encryption in transit and at rest. It records in-person and telehealth visits on iOS, Android, Web, Apple Watch, and Mac, and every note is reviewed and signed by you before it enters the chart.
Join thousands of healthcare professionals who save hours every day with Medical Scribe.