AI Medical Scribe for
A comprehensive eye exam touches fourteen sections of documentation — history, refraction, binocular vision, ocular health, education. Medical Scribe fills them from the exam-room conversation while you stay behind the phoropter.
A real example of the documentation Medical Scribe generates for optometrists — ready before your patient leaves the room.
46M presents for annual exam. Reports increasing difficulty reading his phone and end-of-day eye fatigue with dual-monitor work. No flashes, floaters, or double vision. Last exam 14 months ago.
Illustrative example. Every note is fully editable, and you control the format — SOAP, DAP, or your own custom template.
A full exam covers chief complaint through follow-up criteria. Documenting all of it properly inside the appointment slot — while the next patient is pre-testing — rarely happens.
High-volume routine care pushes notes toward shorthand. Then a patient returns with flashes or a pressure spike, and last year's three-line record tells you almost nothing.
Dry eye management, glaucoma co-management, diabetic eye exams — as your scope grows more medical, your notes must document disease findings and decision-making, not just a spectacle Rx.
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.
History, refraction, slit lamp, dilation, and the wrap-up conversation — Medical Scribe records the visit as it flows and drafts the note in the background. It works for in-person exams and telehealth consults alike, so your documentation keeps pace with a fully booked column.
The Optometrist’s note mirrors how you actually examine: lifestyle and visual demands feed the Lifestyle Assessment; your called-out acuities and refraction land in Visual Acuity and Refractive Status; slit lamp and fundus findings populate Ocular Health Assessment; and your recommendations become the Management Plan, Patient Education, and Follow-Up sections.
When you co-manage glaucoma or defer a cataract referral, the note is your reasoning on the record. Medical Scribe documents only what was said and observed — never inventing findings — so the chart shows the acuities, pressures, and advice that supported your decision.
Yes. The Optometrist's note spans Chief Complaint, Visual History, Medical History, Lifestyle Assessment, Visual Acuity, Refractive Status, Binocular Vision, Ocular Health, Diagnostic Testing, Assessment, Management Plan, Patient Education, and Follow-Up — populated from what's said in the exam room.
Values you speak during the exam — acuities, subjective refraction endpoints, IOPs — are documented as stated. Medical Scribe never invents or fills in a measurement, and you review the draft before it's final.
Shorter, focused visits generate proportionate notes, and you can create custom templates in minutes for contact lens fitting or dry eye clinics — on top of 280+ built-in specialty templates.
Medical Scribe is HIPAA compliant with encryption in transit and at rest, works on iOS, Android, Web, Apple Watch, and Mac, supports 57 languages, and is free to get started — so a multi-doctor practice can trial it without commitment.
Join thousands of healthcare professionals who save hours every day with Medical Scribe.