AI Medical Scribe for
Stay in the room with your client while AI drafts the progress note — session content, interventions, and risk in your format. Stop reconstructing a 50-minute session from memory at 9pm.
A real example of the documentation Medical Scribe generates for psychologists — ready before your patient leaves the room.
28F - Session 8 for generalized anxiety disorder. CBT showing effectiveness. PHQ-9: 8 (mild), GAD-7: 10 (moderate), down from 15 at intake.
Reports improved sleep quality using relaxation techniques. Work-related stressors remain the primary anxiety trigger. Successfully used cognitive restructuring during a work presentation last week. Mood more stable overall; anxiety spikes now shorter and less frequent.
Denies suicidal ideation, self-harm, or homicidal ideation. No substance use reported. No changes to risk status since intake; continue routine monitoring.
Illustrative example. Every note is fully editable, and you control the format — SOAP, DAP, or your own custom template.
A progress note for every session — presentation, interventions, progress toward goals, risk — written after your last client leaves is how caseloads turn into burnout.
Progress notes have to show medical necessity and what you did in session without spilling into psychotherapy-note territory. Getting that boundary right takes time you don't have.
Affect shifts, hesitations, what the client almost said — the clinical material of therapy disappears the moment your attention moves to a keyboard.
Medical Scribe listens to the session — in person or telehealth — and drafts the Psychologist's note: current presentation, session content, interventions, progress and setbacks, risk assessment, and next steps. You review, edit, and sign.
Suicidal ideation, self-harm, and your management plan are documented in a dedicated Risk Assessment and Management section — from what was actually said in session, never invented.
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.
Whether it’s a weekly CBT session, a 90-minute intake, couples work, or telehealth, Medical Scribe records the session and drafts the note that matches it. An initial assessment produces a full clinical interview write-up; a follow-up produces a tight progress note. You stay with the client; the draft is ready when the hour ends.
The built-in Psychologist’s note mirrors how psychologists actually chart: Current Presentation, Past Medical & Psychiatric History, Mental Status Examination, Session Content, Obstacles, Setbacks and Progress, Interventions, Risk Assessment and Management, Session Summary, and Next Steps. Brief but clinically important topics — the offhand disclosure, the small win — make it into the record instead of being lost.
Therapy notes get read — by auditors, by attorneys, sometimes by clients. Medical Scribe documents only what was actually said and observed, keeps risk assessment and your management plan in their own section, and never fills gaps with invented findings. Every note is yours to edit and sign before it touches the chart.
Medical Scribe drafts the progress note — the official record of presentation, interventions, risk, and plan. Your private psychotherapy (process) notes remain separate and yours. You control exactly what goes in the chart, because you review and edit every note before signing.
Yes. It supports SOAP, DAP, and custom formats, and includes the built-in Psychologist's note and Psychology Initial Assessment templates among 280+ specialty templates. If your practice uses BIRP or an agency-specific structure, you can build a custom template in minutes.
The same way they would with any scribe or trainee: you inform them and ask. Many practices add a line to their intake paperwork. Recordings are encrypted in transit and at rest, and Medical Scribe is HIPAA compliant.
No. The note only documents what was said and observed in the session. If risk wasn't discussed or a mental status observation wasn't verbalized, that section stays blank rather than being filled with plausible-sounding text.
Join thousands of healthcare professionals who save hours every day with Medical Scribe.