AI Medical Scribe for
A COPD follow-up packs spirometry trends, inhaler changes, and a nodule check into twenty minutes — then the note takes thirty. Medical Scribe drafts your subjective, ROS, exam, and problem-by-problem impression and plan while you're still talking to the patient.
A real example of the documentation Medical Scribe generates for pulmonologists — ready before your patient leaves the room.
67M with COPD (GOLD 3, group E) for 3-month follow-up. One moderate exacerbation since last visit, managed as an outpatient with prednisone and azithromycin. Baseline dyspnea mMRC 2. Using budesonide/formoterol BID plus tiotropium daily; inhaler technique re-checked today. Quit smoking 2 years ago after 45 pack-years.
SpO2 93% on room air, RR 16. Prolonged expiratory phase with scattered end-expiratory wheeze; no accessory muscle use, no clubbing or cyanosis. Trace bilateral pitting edema.
Illustrative example. Every note is fully editable, and you control the format — SOAP, DAP, or your own custom template.
COPD plus suspected OSA plus a nodule under surveillance — in one appointment. Each problem needs its own impression, investigations, and plan, and the note triples accordingly.
FEV1 and FVC, DLCO, CAT scores, six-minute walk distance, AHI, home oxygen settings — pulmonary notes are dense with data that has to land in the right place, exactly.
Pack-years, occupational and environmental exposures, exacerbation counts, prior regimens — the history that drives pulmonary decisions takes longer to type than to take.
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 new dyspnea consults, COPD and asthma follow-ups, ILD reviews, and sleep medicine visits — in clinic or over telehealth — and drafts a complete note for each. You keep your eyes on the patient’s work of breathing instead of a keyboard.
Drafts follow the built-in Pulmonologist’s note template: Subjective with full smoking and exposure history, a systematic Review of Systems, and Objective sections for examination, investigations, and a numbered Impression & Plan per problem. It’s one of 280+ templates, with custom variants ready in minutes.
Pulmonary decisions hinge on exact values, and a transposed FEV1 changes the GOLD stage. Medical Scribe documents only what was said and observed in the visit — never an invented number or exam finding — and every note is yours to verify and sign before it reaches the chart.
Values you state during the visit — FEV1, DLCO, CAT, Epworth, oxygen settings — are captured as said and placed in the investigations and plan sections. Medical Scribe never fabricates a value; if a number wasn't spoken, it isn't in the note.
Yes. The built-in Pulmonologist's note structures the assessment as a numbered, problem-by-problem impression and plan — diagnosis, differentials, investigations, treatment, and referrals for each issue — instead of one merged paragraph.
Yes. Sleep consults and CPAP follow-ups record the same way, and there's even a built-in Sleep Study Consent template. Custom templates for your sleep lab's format take minutes to set up.
The scribe simply captures the visit as it happens — including history given by an accompanying family member — and only documents what was actually said. It works for in-person and telehealth visits, is HIPAA compliant, and you sign every note.
Join thousands of healthcare professionals who save hours every day with Medical Scribe.