AI Medical Scribe for
Goals-of-care conversations deserve your full attention — and a note that records exactly what was said. Medical Scribe captures symptom assessments, family meetings, and code status discussions in a note you review and sign.
A real example of the documentation Medical Scribe generates for palliative care physicians — ready before your patient leaves the room.
71M with stage IV NSCLC (osseous and hepatic metastases) — inpatient consult for dyspnea, chest wall pain, and goals of care. ECOG 3.
Reports breathlessness at rest, better sitting upright, and constant right chest wall pain 7/10 despite oxycodone 10mg q4h PRN. Fatigue limits conversation. States he 'wants to be home for whatever time is left.' Wife present and in agreement; both demonstrate clear understanding of prognosis.
Illustrative example. Every note is fully editable, and you control the format — SOAP, DAP, or your own custom template.
A 60-minute goals-of-care meeting has multiple voices, shifting positions, and one crucial conclusion. Reconstructing it from memory that evening flattens the nuance the chart needs to carry.
What the patient or surrogate actually said about resuscitation, intubation, and hospice carries clinical, ethical, and legal weight. A paraphrase from memory is not the same record.
A palliative consult service moves ward to ward all day. Each encounter — symptom crisis, prognosis discussion, hospice transition — stacks another note onto an already late evening.
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.
Palliative medicine runs on conversation: symptom review, prognostic disclosure, values, trade-offs. Medical Scribe records the encounter — bedside consult, family meeting, or telehealth check-in — and drafts the note while you move to the next ward. Long meetings become structured documentation instead of an evening reconstruction exercise.
The Palliative Care Physician’s note template structures each encounter into Subjective, Objective, and Assessment & Plan — ESAS scores, opioid rotations with doses, and the goals-of-care outcome each in their place. Teams that chart DAP or DARP have those built-in templates too, among 280+ specialty formats with custom ones in minutes.
No specialty depends more on documenting what a patient actually said. Medical Scribe only writes what was spoken and observed in the encounter — it will never attribute a wish, a preference, or an understanding that wasn’t expressed. Encrypted in transit and at rest, and nothing stands as the record until you have reviewed and signed it.
It documents what was actually said in the room — the patient's stated wishes, the surrogate's input, and the decision reached — and never invents or infers a preference. You review every word and sign before the note becomes part of the chart.
Yes. The note is generated from the whole conversation, including family members' questions and concerns, so the record reflects who raised what — the context that matters when decisions are revisited later.
The built-in Palliative Care Physician's note template drafts Subjective, Objective, and Assessment & Plan sections with symptom scores and psychosocial context; DAP and DARP templates are also built in, and custom formats take minutes to create.
Medical Scribe is HIPAA compliant with encryption in transit and at rest. Patients and families are informed and consent as they would with any scribe — and many appreciate a physician who is fully present instead of typing.
Join thousands of healthcare professionals who save hours every day with Medical Scribe.