AI Medical Scribe for
Six clients a day means six progress notes threading presentation, interventions, and progress toward goals — before tomorrow's six arrive. Medical Scribe drafts each note from the session itself, so the golden thread writes itself.
A real example of the documentation Medical Scribe generates for psychotherapists — ready before your patient leaves the room.
29F with generalized anxiety disorder, CBT session 6 of a planned 12. Reports anxiety 'more manageable' this week. GAD-7 today 8, down from 15 at intake. One episode of racing heart before a work presentation, resolved with paced breathing.
Reviewed thought records from the week. Worked on cognitive restructuring of catastrophic predictions about workplace evaluation ('If I stumble, I'll be fired'). Introduced rationale for interoceptive exposure and collaboratively built the first hierarchy items.
Homework: two interoceptive exposure trials (straw breathing, stair climb) with SUDS ratings, plus daily thought records. Next session scheduled in one week; will review exposure response and re-administer GAD-7 at session 8.
Illustrative example. Every note is fully editable, and you control the format — SOAP, DAP, or your own custom template.
With ten minutes between clients, progress notes pile up until evening — when the details of session three have already blurred into session six.
Payers expect every note to connect presentation, intervention, and measurable progress back to the treatment plan. A missing link is a recoupment risk, not a formality.
Attunement, silence, watching what the body says — the therapeutic work happens in your attention. Splitting it with a notepad costs the client and the note both.
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.
Medical Scribe records in-person and telehealth sessions and drafts the progress note when the hour ends — current presentation, session content, interventions, progress, and next steps. Fifty minutes of therapy produces a note in the time it takes to walk your client out.
Drafts follow the built-in Psychotherapist’s note template: Current Presentation, Mental Status Examination, Session Content, Obstacles, Setbacks and Progress, Interventions, Risk Assessment and Management, Session Summary, and Next Steps. Prefer DAP or your group practice’s own format? Both are supported, and custom templates take minutes.
When a client discloses ideation or self-harm, what you asked and what they answered matters. Medical Scribe documents the risk conversation and your stated management plan from the session itself — never a reconstructed summary from memory at 9pm — and you review every word before signing.
Progress notes — the part of the record payers and other providers may see. Your private psychotherapy (process) notes, which HIPAA treats separately, remain your own. Medical Scribe drafts the official progress note; you decide what belongs there.
Yes. Medical Scribe supports SOAP, DAP, and fully custom formats, and includes built-in Psychotherapist's note and Psychotherapy Note templates among 280+ — with sections for session content, interventions, progress, and risk.
The generated note links what the client presented with, which interventions you used, and progress toward treatment-plan goals — the golden thread reviewers look for. It documents only what actually happened in session, and you review and sign every note.
Recording happens only with informed consent, as with any scribe. Sessions are encrypted in transit and at rest, the platform is HIPAA compliant, and you control the recordings. Many clients prefer a therapist who isn't typing.
Join thousands of healthcare professionals who save hours every day with Medical Scribe.