AI Medical Scribe for
Pre-op assessments, PACU checks, and handoffs happen in minutes-long windows between patients. Medical Scribe drafts your assessment, interventions, and evaluation as you speak them.
A real example of the documentation Medical Scribe generates for perioperative nurses — ready before your patient leaves the room.
61F, post laparoscopic cholecystectomy under general anesthesia, arrived PACU 10:42 from OR 3. Anesthesia report received; intraoperative course described as uneventful.
Reports incisional pain 5/10, sharp, localized to the umbilical port site. Describes nausea as mild. Oriented to events; asking when she can have water and when her daughter can come back.
Wean oxygen as tolerated; advance to sips of water when fully alert. Anticipate transfer to day-surgery unit when Aldrete score is 9 or above. Handoff to receiving nurse to include pain trajectory, PONV management, and mobility status; discharge teaching on wound care and activity to follow on the unit.
Illustrative example. Every note is fully editable, and you control the format — SOAP, DAP, or your own custom template.
The next patient is rolling in while you're still documenting the last one's vitals, medications given, and response — accuracy and speed pull in opposite directions.
Pre-op assessment, intraoperative events, PACU course, discharge readiness — one patient can mean four separate structured entries in a single shift.
The receiving nurse acts on your note. Missing intervention times, unrecorded responses, or a thin evaluation become someone else's clinical blind spot.
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.
Speak your assessment at the bedside — the pre-op interview, PACU arrival vitals, medications given and the patient’s response — and Medical Scribe drafts the structured entry while you move to the next bay. It works at the bedside on iOS, Android, Web, Apple Watch, or Mac, in person or for pre-admission telehealth calls.
Drafts follow the built-in Perioperative Nurse’s note: Patient Information, Subjective with the patient’s own pain and concerns, Objective with vitals and physical assessment, your nursing Assessment and Plan, then Interventions with responses, Evaluation, and Plan for Continuing Care. Patient and family education lands in additional notes. One of 280+ templates, customizable in minutes.
Perioperative care is a relay, and your note is the baton. Medical Scribe documents only what you actually said and observed — real times, real doses, real responses, nothing invented — and you review and sign before it enters the record, so the nurse receiving your patient inherits facts, not gaps.
It's built for nursing process documentation. The Perioperative Nurse's note runs Patient Information, Subjective, Objective, Assessment, Plan, Interventions, Evaluation, and Plan for Continuing Care — assessment through evaluation, the way nurses actually chart.
What you say is what's documented — 'fentanyl 25 micrograms IV at 10:55, pain down to 2 out of 10 at 11:15' lands under Interventions with the response recorded. It never invents times, doses, or responses, and you review before signing.
Yes — the apps run on iOS, Android, Web, Apple Watch, and Mac, so you can capture the encounter at the bedside. Patients are informed and consent as they would to any documentation; Medical Scribe is HIPAA compliant and encrypted in transit and at rest.
The built-in Perioperative Nurse's note is one of 280+ templates, and SOAP, DAP, or a custom structure matching your unit's required fields can be set up in minutes.
Join thousands of healthcare professionals who save hours every day with Medical Scribe.