AI Medical Scribe for
Four problems in a 20-minute visit, and each one needs its own history, review of systems, and plan. Medical Scribe drafts the full note — Subjective through Impression & Plan — while you stay with the patient.
A real example of the documentation Medical Scribe generates for physicians — ready before your patient leaves the room.
58M presenting for 3-month follow-up of type 2 diabetes and hypertension, with new right knee pain. Reports good adherence to metformin 1000mg BID and lisinopril 20mg daily. Knee pain began ~6 weeks ago, worse with stairs, no trauma. Denies chest pain, dyspnea. No known drug allergies. Former smoker, quit 2019.
Illustrative example. Every note is fully editable, and you control the format — SOAP, DAP, or your own custom template.
A patient with diabetes, hypertension, and new knee pain needs a separate assessment and plan for each issue. Charting three problems properly takes longer than the visit itself.
Unfinished encounters pile up through the day, and the review of systems, exam findings, and clinical reasoning get reconstructed from memory at 9pm — when detail is already fading.
History, exam, and medical decision-making all have to be on the page to support the visit level. Thin documentation means downcoding; padding it by hand means more typing.
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.
Clinic follow-ups, new complaints layered on chronic disease, urgent add-ons, telehealth checks — Medical Scribe records each encounter and drafts a complete Physician’s note from the conversation. The history of presenting illness, medication changes, and your spoken exam findings land in the right sections while you move to the next room. You review, edit, and sign.
The generated note follows the Physician’s note template: Subjective with reason for visit, HPI, medications, and allergies; a Review of Systems built from what you actually asked; Objective with examination and investigations; and an Impression & Plan that gives each problem its own assessment, workup, and treatment.
A chart note is a medico-legal record. Medical Scribe documents only what was said and observed in the encounter — it never fabricates exam findings, lab values, or ROS elements you didn’t elicit. If it wasn’t discussed, it isn’t in the note, and you sign off on every line before it reaches the chart.
Yes. The Physician's note template structures the note into Subjective, Review of Systems, Objective, and Impression & Plan, with each problem assessed and planned separately — a three-problem visit produces three distinct assessments, not one blurred paragraph.
The note captures the history, examination findings, and clinical reasoning actually discussed in the encounter — the elements coders and auditors look for. It documents only what was said and observed, and you review and sign before anything enters the chart.
Yes. Medical Scribe records in-person and telehealth visits, with apps for iOS, Android, Web, Apple Watch, and Mac — and it works in 57 languages.
Use either. There are 280+ built-in specialty templates including the Physician's note, plus SOAP, DAP, and custom formats — you can build a template matching your own note style in minutes.
Join thousands of healthcare professionals who save hours every day with Medical Scribe.