AI Medical Scribe for
Stay fully present during med checks and intakes while AI drafts your MSE, risk assessment, and treatment plan. Notes that hold up to utilization review — done before your next patient.
A real example of the documentation Medical Scribe generates for psychiatrists — ready before your patient leaves the room.
34M — Follow-up for major depressive disorder, single episode, moderate. Week 6 on sertraline 100mg. PHQ-9 down from 18 to 9. Tolerating well, mild early insomnia.
Reports steady improvement in mood and motivation over past 3 weeks. Returned to gym twice weekly. Appetite normalized. Sleep onset delayed ~45 minutes, denies early waking. No missed doses. Denies suicidal ideation, plan, or intent.
Denies suicidal ideation, intent, or plan. No access to firearms. Protective factors: engaged in treatment, strong family support, future-oriented. Overall risk: low.
Illustrative example. Every note is fully editable, and you control the format — SOAP, DAP, or your own custom template.
Follow-up visits are short, but documenting the MSE, medication response, side effects, and risk assessment for each one adds up to hours of after-hours notes.
Suicidality, self-harm, and safety planning need to be captured precisely and defensibly — vague notes are a clinical and legal liability.
Patients disclose less when you're looking at a screen. Psychiatric assessment depends on observing affect, speech, and behavior — hard to do mid-keystroke.
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.
A psychiatric visit is a conversation — and the richer the conversation, the harder it is to chart. Medical Scribe listens to the visit (in person or telehealth) and drafts a complete psychiatric note: presenting complaints, medication history, mental status examination, risk assessment, diagnosis, and plan. You review, edit, and sign.
Risk language matters. The generated note records what the patient actually said about ideation, intent, plan, and protective factors — in a dedicated risk assessment section — so your chart reflects your clinical care, not a rushed summary of it.
Yes. The psychiatrist note template includes dedicated Mental Status Examination, Risk Assessment, and Safety Plan sections, populated only from what was actually said and observed in the visit — it never invents clinical findings.
Medical Scribe is HIPAA compliant with encryption in transit and at rest. Recordings are processed securely, you control retention, and patients can be informed and consent just as they would with any scribe.
Yes. A 60-90 minute intake generates a full psychiatric evaluation with history, MSE, diagnosis, and treatment plan; a 15-minute med check produces a concise follow-up note. The note matches the visit, not a one-size template.
Notes capture symptom severity, functional impact, medication response, and clinical reasoning in structured sections — the elements reviewers look for. You always review and sign before anything goes in the chart.
Join thousands of healthcare professionals who save hours every day with Medical Scribe.