AI Medical Scribe for
Cover tests, prism measurements, and a five-year-old who won't sit still — orthoptic assessment takes both your hands and all your attention. Medical Scribe writes the note from what you say in the room, measurements included.
A real example of the documentation Medical Scribe generates for orthoptists — ready before your patient leaves the room.
5F referred after failed school vision screening. Parents have noticed the left eye turning in when she is tired, over roughly 6 months. Wearing her first hyperopic correction (+3.00 OD, +3.50 OS) full time for 6 weeks.
Partially accommodative esotropia with moderate amblyopia OS, improving on full-time hyperopic correction. Residual deviation persists with glasses in place.
Illustrative example. Every note is fully editable, and you control the format — SOAP, DAP, or your own custom template.
Keeping a child engaged through cover testing, motility, and stereopsis leaves no hands free for a keyboard — so measurements get scribbled and notes get written after clinic.
Deviation at distance and near, with and without correction; acuity by age-appropriate charts — patching and prism decisions depend on comparing exact values across visits.
Months of reviews tracking compliance, acuity change, and regimen adjustments — each needs consistent documentation so the trend stays readable to you and the ophthalmologist.
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.
Strabismus assessments, amblyopia reviews, diplopia workups — Medical Scribe records the visit while you test, in person or over telehealth, and drafts the note from your spoken findings. Call out the cover test result as you measure it; it’s in the draft before the child has picked a sticker.
The Orthoptist’s note documents Chief Complaint, Visual History, Visual Acuity, Binocular Vision and Eye Movement, Assessment, Management Plan, Patient Education, and Follow-Up in the same order every visit — so acuity trends, deviation changes, and patching adjustments line up cleanly across months of amblyopia therapy.
Surgical planning and patching decisions ride on your measurements. Medical Scribe documents only the values you actually stated during testing — it never invents or rounds a finding — so the co-management record reflects your assessment with nothing added and nothing lost.
Yes. Prism diopter deviations, cover test results at distance and near, motility findings, and stereopsis values you state during testing are documented in the Binocular Vision and Eye Movement and Visual Acuity sections of the Orthoptist's note — never estimated or invented.
It records the visit conversation and drafts the note from what was actually said. You review and edit the draft before signing, so you stay in control of exactly what enters the record.
As with any scribe, patients — or parents, for minors — can be informed and consent before recording. Medical Scribe is HIPAA compliant with encryption in transit and at rest, and supports 57 languages for families who speak them.
Yes. The Orthoptist's note follows the same structured ocular exam flow used across eye care — Chief Complaint through Assessment, Management Plan, and Follow-Up — so co-managing ophthalmologists can find your measurements and plan immediately.
Join thousands of healthcare professionals who save hours every day with Medical Scribe.