AI Medical Scribe for
Function is your outcome — and documenting it means goals, serial measures, and multi-system exams at every visit. Medical Scribe drafts the full PM&R note, from current condition through plan, while you assess.
A real example of the documentation Medical Scribe generates for physical medicine and rehabilitation specialists — ready before your patient leaves the room.
58M, 8 months post left MCA ischemic stroke, follow-up for right upper-limb spasticity. Reports increasing difficulty dressing — the elbow 'pulls in' during transfers and sleeve entry. Night-time tightness wakes him about twice weekly despite the home stretching program.
Post-stroke right hemiparesis with focal upper-limb spasticity now limiting dressing and transfers, progressing despite consistent home stretching. Appropriate candidate for repeat botulinum toxin injection with occupational therapy follow-through.
Illustrative example. Every note is fully editable, and you control the format — SOAP, DAP, or your own custom template.
Mobility, transfers, ADLs, work demands, and equipment use can't be reduced to a checkbox — every physiatry note carries paragraphs of functional description.
Modified Ashworth scores, range-of-motion degrees, strength grades, and pain scales get re-measured and re-charted visit after visit to prove trajectory.
PT, OT, orthotists, and referring surgeons all work from your note — so goals, precautions, and therapy orders have to be spelled out completely, every time.
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.
Spasticity clinics, post-stroke and spinal cord injury follow-ups, musculoskeletal consults, and interdisciplinary team reviews all record the same way — in person or telehealth, from iOS, Android, Web, Apple Watch, or Mac. Medical Scribe drafts the note during the encounter, so an hour of functional assessment doesn’t cost a second hour of typing.
Drafts follow the built-in Physical Medicine and Rehabilitation Specialist’s note: Patient Information with work demands and activity levels, Medical and Social History, Current Condition/Complaint, Patient Goals with time frames, Objective measurements, Treatment delivered, Assessment, and Plan including equipment, home exercise programs, and referrals. DAP and DARP formats are built in too — among 280+ templates.
Continued therapy, repeat injections, and equipment funding all hinge on documented trajectory. Medical Scribe records only the measures and observations actually stated in the visit — never inventing a score — so when a reviewer compares this quarter’s Ashworth grades to last quarter’s, both numbers are genuinely yours.
Scores you state during the exam — Modified Ashworth grades, ROM degrees, MMT strength grades, VAS pain — are documented exactly as said, never estimated or carried forward from a prior note. You verify every value before signing.
Yes. The Physical Medicine and Rehabilitation Specialist's note has a dedicated Patient Goals section with short- and long-term goals and time frames, distinct from your Assessment and Plan — the structure functional-progress reviews and payers look for.
Yes — alongside the full PM&R template, built-in DAP and DARP formats suit brief re-checks, and custom templates take minutes. All are drawn from the same visit recording, in person or telehealth.
Medical Scribe is HIPAA compliant and encrypted in transit and at rest. Patients consent to recording as they would to any scribe, and nothing enters the chart until you review and sign it.
Join thousands of healthcare professionals who save hours every day with Medical Scribe.