AI Medical Scribe for
Obs rounds, meds, dressing changes, and parents' questions come first — so nursing notes get batched at end of shift, when the detail is already fading. Medical Scribe drafts structured nursing documentation from what happens at the bedside.
A real example of the documentation Medical Scribe generates for pediatric nurses — ready before your patient leaves the room.
5M, day 1 post laparoscopic appendectomy. Reports pain 3/10 on Wong-Baker FACES at rest, 5/10 with movement. Passed flatus this morning. Mother at bedside, asking when normal diet can resume.
Pain reduced to 1/10 at rest following analgesia. Tolerating light diet without nausea or vomiting. Mobilizing well. Mother verbalized understanding of wound care teaching.
Anticipate discharge tomorrow if diet tolerated and afebrile overnight. Complete discharge teaching with both parents; surgical clinic follow-up in 2 weeks to be confirmed before discharge.
Illustrative example. Every note is fully editable, and you control the format — SOAP, DAP, or your own custom template.
Between a full patient load and call bells, notes are written hours after the assessment — and a FLACC score or a parent conversation recalled at 6 pm isn't as sharp as it was at 10 am.
Med administration, wound care, feeds, education given to parents, and the child's response — each one documented, per patient, per shift. The volume is relentless.
The next shift acts on what you wrote. Thin or delayed documentation means questions at handover and gaps in continuing care for kids who can't speak for themselves.
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.
Assess the child, give the meds, teach the parent — Medical Scribe records the encounter as it happens and drafts the note before you’ve moved two rooms down. The FLACC score, the mother’s question, and the child’s response to analgesia are documented while they’re still fresh, not reconstructed at 18:45.
Drafts follow the built-in Pediatric Nurse’s note: Patient Information, Subjective including the child’s and family’s own words, Objective with vitals and physical assessment, Assessment, Plan, Interventions with responses, Evaluation, and Plan for Continuing Care. It’s one of 280+ built-in templates, and ward-specific custom formats take minutes.
The nurse taking over — and the whole team after them — relies on your note being complete and true. Medical Scribe documents only what was said and observed during care, never inferred findings, and every note is reviewed and signed by you before it joins the record.
Yes. The built-in Pediatric Nurse's note runs from Patient Information and Subjective through Objective, Assessment, Plan, Interventions, Evaluation, and Plan for Continuing Care — the full nursing process, not a physician SOAP note. DAP and custom formats are available too.
Exactly and only as stated — a Wong-Baker or FLACC score, a temperature, an intake volume. Medical Scribe never invents an observation; if you didn't say it or observe it in the encounter, it isn't in the draft.
Yes. Apps for iOS, Android, Web, Apple Watch, and Mac mean you can capture an assessment at the bedside from your phone or watch, then review and sign the drafted note when you're back at the station.
Medical Scribe is HIPAA compliant with encryption in transit and at rest. Use it in line with your facility's policy, and inform and consent parents as you would for any documentation support.
Join thousands of healthcare professionals who save hours every day with Medical Scribe.