AI Medical Scribe for
Every contact needs an MSE, a risk assessment, and a safety plan that will stand up if something goes wrong — multiplied across a full caseload. Medical Scribe drafts the structured note from the conversation so charting doesn't outlast the shift.
A real example of the documentation Medical Scribe generates for psychiatric nurses — ready before your patient leaves the room.
29F reviewed at community mental health clinic, 4 weeks after starting escitalopram 10mg daily for major depressive disorder with comorbid generalized anxiety. Reports mood 'a bit lighter', improved sleep (6-7 hours), reduced morning dread. GAD-7 today 11, down from 17 at intake. Attending work 4 days of 5. Denies medication side effects apart from transient nausea in week one, now resolved.
Denies suicidal ideation, intent, or plan. No self-harm since engagement with service. Protective factors: supportive partner, re-engagement with work, help-seeking behavior. Risk to self assessed as low; no risk to others identified.
Illustrative example. Every note is fully editable, and you control the format — SOAP, DAP, or your own custom template.
If a patient is harmed, your risk assessment and safety plan are the first pages reviewed. Documenting ideation, intent, and protective factors precisely — every contact — is non-negotiable and slow.
Depot clinics, community visits, and crisis reviews each demand a documented mental status examination. Ten contacts a day means ten structured MSEs, usually typed after handover.
Rapport is the working tool of psychiatric nursing. Patients guard their disclosures when you're typing, but affect, speech, and behavior are exactly what you're there to observe.
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.
Depot and medication reviews, community follow-ups, intake assessments, crisis contacts, telehealth check-ins — Medical Scribe records each conversation and drafts the structured note while you give the patient your full attention. The observations you’d normally hold in your head until handover are already in the draft when the contact ends.
The built-in Psychiatric Nurse’s note template covers History of Presenting Complaints, Past Medical & Psychiatric History, Medications, Family and Social History, Mental Status Examination, Risk Assessment, Diagnosis, Treatment Plan, and Safety Plan. When your service requires care-plan documentation, the Mental Health Care Plan template drafts that from the same visit.
Risk notes are scrutinized retrospectively, so precision protects patients and clinicians alike. Medical Scribe records what the patient actually said about ideation, intent, and protective factors — and what you actually observed — without inventing or softening anything. Your clinical judgment stays yours: every note is reviewed and signed by you before it stands in the record.
Yes. The Psychiatric Nurse's note template has dedicated sections for the Mental Status Examination, Risk Assessment, Treatment Plan, and Safety Plan — populated only from what was said and observed in the contact. It never generates risk language you didn't assess.
Yes. Alongside the Psychiatric Nurse's note, the built-in Mental Health Care Plan template drafts the structured plan — problem/diagnosis, clinical details, MSE, formulation, patient education, and review arrangements — from the same recorded conversation.
Medical Scribe is HIPAA compliant with encryption in transit and at rest. Patients are informed and consent just as they would with any scribe, and you review and sign every note before it enters the record.
Yes. Apps for iOS, Android, Web, Apple Watch, and Mac record in-person and telehealth contacts, and it works in 57 languages — useful across a diverse community caseload.
Join thousands of healthcare professionals who save hours every day with Medical Scribe.