AI Medical Scribe for
A child assessment weaves together the child's play, the parent interview, and school reports — then demands a structured write-up. Medical Scribe drafts the clinical interview, formulation, and treatment plan so your attention stays in the room.
A real example of the documentation Medical Scribe generates for pediatric psychologists — ready before your patient leaves the room.
Sleep onset delayed past 10:30 pm, requires parent present. Appetite normal. Friendships intact but declining playdate invitations. Previously strong grade 4 student; incomplete work accumulating. Enjoys gymnastics and still attends weekly.
Well-groomed, initially reticent, warmed during drawing task. Speech normal in rate and volume. Mood 'worried'; affect anxious but reactive with full range. Thought process age-appropriate. No perceptual disturbance. Denies thoughts of self-harm; no risk indicators elicited from child or parent.
Predisposing: temperamental behavioural inhibition; maternal anxiety disorder. Precipitating: school transfer in September. Perpetuating: avoidance cycle reinforced by comfort of home days and parental accommodation. Protective: warm, motivated parents; strong peer relationships; child expresses desire to return.
Illustrative example. Every note is fully editable, and you control the format — SOAP, DAP, or your own custom template.
With children, observation is the assessment — behaviour, affect, and parent-child interaction. Every glance at a keyboard is data missed.
Presenting problems, developmental milestones, school functioning, family dynamics, and risk — gathered from parent and child separately — all have to land in one coherent note.
Intake write-ups with predisposing, precipitating, perpetuating, and protective factors plus DSM-5-TR-aligned treatment goals routinely take longer than the session itself.
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.
Whether it’s a 90-minute intake with a parent interview, a play-based session, or a telehealth check-in, Medical Scribe records the appointment and drafts a structured note from what was actually said and observed. You stay on the floor with the child, then review and sign from iOS, Android, Web, Apple Watch, or Mac.
Drafts follow the built-in Pediatric Psychologist’s note: a Clinical Interview capturing presenting problems, current functioning, developmental history, risk assessment, mental state exam, and clinical formulation with predisposing, precipitating, perpetuating, and protective factors — then a Treatment Plan with DSM-5-TR diagnoses, goals, and outcome measures. One of 280+ templates, customizable in minutes.
When a child or parent discloses self-harm, aggression, or safety concerns, precision matters clinically and legally. Medical Scribe records what was disclosed — verbatim source material, never inferred risk language — in a dedicated Risk Assessment section, and nothing enters the record until you’ve reviewed and signed it.
A clinical record note — the kind that belongs in the chart. The built-in Pediatric Psychologist's note covers the clinical interview, risk assessment, mental state exam, formulation, and a DSM-5-TR-aligned treatment plan. Your private process notes stay yours.
The same as with any scribe: the parent or guardian consents, and the child assents where appropriate. Medical Scribe is HIPAA compliant and encrypted in transit and at rest, and you control recording and retention.
Yes. Record each part of the appointment and the note integrates them, attributing history to its source — parent report versus the child's own account — which matters when the two diverge.
If you state results — an SCAS score, a WISC index, a Conners rating — they appear under Formal Psychometric Assessments. It only documents what was actually said; it never generates scores or findings on its own.
Join thousands of healthcare professionals who save hours every day with Medical Scribe.