AI Medical Scribe for
You review patients through weeks of daily fractions — grading skin reactions, tracking fatigue, escalating toxicities — then chart it all between treatment slots. Medical Scribe drafts the full nursing note from the review conversation so you stay at the chairside, not the keyboard.
A real example of the documentation Medical Scribe generates for radiotherapy nurses — ready before your patient leaves the room.
58F receiving adjuvant radiotherapy to the right breast, fraction 18 of 25. Reports increasing warmth and itch over the treatment field for 4 days. Fatigue 4/10, worse by evening but managing daily activities. Pain 2/10 over the axilla, relieved by paracetamol 1g PRN. Understands remaining schedule and expected peak of skin reaction after completion.
Expected grade 2 radiation dermatitis progressing in line with dose delivered. Fatigue mild and stable. No indication for treatment interruption at this stage; skin integrity and comfort are the priority care needs.
Continue daily fractions as scheduled. Nursing review at fraction 21 or sooner if skin breaks down. Repeat weight and pain score at next review. Post-treatment skin check booked for 2 weeks after final fraction.
Illustrative example. Every note is fully editable, and you control the format — SOAP, DAP, or your own custom template.
Weekly treatment reviews are booked back-to-back around machine schedules. Documenting toxicity grading, symptom management, and patient education for each one pushes charting into breaks that don't exist.
A course of radiotherapy means serial notes on evolving skin reactions, fatigue, mucositis, and swallowing — each entry needs enough detail to show progression from the last, not a copy-paste of it.
Skin reaction grades, weight loss, and pain scores drive treatment interruptions and medical escalation. Thin or inconsistent nursing entries make those decisions harder to justify later.
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.
Radiotherapy nursing is serial care: baseline assessment, weekly on-treatment reviews, side-effect checks between fractions, and post-treatment follow-up. Medical Scribe records each encounter — in person or via telehealth — and drafts the review note while you move to the next patient, so a full review clinic doesn’t leave a stack of unwritten entries.
The built-in Radiotherapy Nurse’s note template — one of 280+ specialty templates — mirrors how you already document: Patient Information, Subjective, Objective, Assessment, Plan, Interventions, Evaluation, and Plan for Continuing Care. Skin reaction grades, pain scores, weight trends, education given, and escalations land in the right section automatically.
Treatment interruptions and medical escalations hinge on what nursing documented week by week. Medical Scribe records only what was said and observed in the review — it never invents a grade, a finding, or a patient statement — and you sign every note, so the toxicity trail in the chart reflects your actual assessments.
Yes — whatever grading you state during the review is captured exactly where it belongs. The Radiotherapy Nurse's note template has dedicated Objective and Assessment sections, and the note only records grades and findings you actually voiced, never ones it infers.
Each review generates its own note from that day's conversation, so fraction 18 reads differently from fraction 5 because the patient's condition did. You get genuine progression in the record instead of cloned entries.
Medical Scribe is HIPAA compliant, with recordings encrypted in transit and at rest. It works on iOS, Android, Web, Apple Watch, and Mac, so you can capture a review wherever it happens and process it securely.
Always. The AI drafts the note; you review, edit, and sign before anything enters the record. Nothing is filed without a nurse's eyes on it.
Join thousands of healthcare professionals who save hours every day with Medical Scribe.