AI Medical Scribe for
Physiatry visits cover multiple problems at once — spasticity, pain, function, equipment, therapy orders — and the note has to organize all of it by issue. Medical Scribe drafts a problem-structured note from the consultation while you stay focused on the functional exam.
A real example of the documentation Medical Scribe generates for rehabilitation medicine specialists — ready before your patient leaves the room.
62M, 4 months post left MCA ischemic stroke with right hemiparesis, attending with his wife. Reports right elbow and finger tightness interfering with dressing and hygiene. Shoulder pain 4/10 with overhead reach. Walking indoors with a single-point cane; one near-fall last month, no injury. Medications: baclofen 10mg TID, apixaban 5mg BID, atorvastatin 40mg daily. Attending outpatient PT twice weekly.
Focal spasticity of elbow and finger flexors limiting dressing and hygiene, incompletely controlled on oral baclofen. Plan: botulinum toxin injection to biceps, FDS, and FDP discussed and agreed; scheduled next month. Continue baclofen at current dose. OT referral for post-injection stretching and splint review.
Shoulder pain consistent with soft-tissue impingement in the hemiparetic shoulder; continue PT with scapular program, add ultrasound if not improving in 6 weeks. Near-fall with community ambulation goal: PT to progress balance training; ankle-foot orthosis assessment ordered. Review in 8 weeks with repeat MAS and gait review.
Illustrative example. Every note is fully editable, and you control the format — SOAP, DAP, or your own custom template.
A single follow-up can span spasticity management, neuropathic pain, neurogenic bladder, seating, and therapy progress. Documenting each issue with its own assessment and plan turns a 30-minute visit into 30 minutes of typing.
Range of motion in degrees, MRC strength grades, Modified Ashworth scores, gait observations — the numbers you call out during the exam are exactly the ones that prove functional change over time.
PTs, OTs, speech therapists, orthotists, and referring physicians all act on your documentation. Vague therapy orders or missing referral rationale creates rework across the entire rehab team.
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 new consultation for post-stroke spasticity, an inpatient rehab review, or a telehealth follow-up on pain and function, Medical Scribe records the visit and drafts the complete note — history, functional exam, and an issue-by-issue plan. You verify the numbers, adjust the plan wording, and sign.
The built-in Rehabilitation Medicine Specialist’s note template — one of 280+ specialty templates — organizes each visit into Subjective, Objective, and a problem-based Assessment & Plan: for every issue, the diagnosis, differentials, investigations, rehabilitation strategies, assistive devices, and referrals to PT, OT, or speech therapy. Custom formats take minutes if your service documents differently.
Demonstrating functional change is the currency of rehabilitation medicine. Medical Scribe records the Ashworth grades, ROM degrees, and strength scores you actually voiced — it never invents or interpolates a finding — so serial notes give you a clean, comparable record of whether your patient is progressing.
Yes. The Rehabilitation Medicine Specialist's note template uses an issue-by-issue Assessment & Plan — each problem gets its own diagnosis, investigations, treatment, and referrals — so a multi-problem visit produces a note structured the way you think.
The measurements you speak during the exam are transcribed into the Objective section as stated. Nothing is estimated or filled in: if you didn't say it, it isn't in the note.
Referrals and therapy plans you dictate — including frequency, focus, and rationale — are written into each issue's plan, giving PT, OT, and orthotics an actionable order rather than a vague 'continue therapy.'
Both. Medical Scribe records in-person and telehealth visits across iOS, Android, Web, Apple Watch, and Mac, and it's HIPAA compliant with encryption in transit and at rest. You review and sign every note.
Join thousands of healthcare professionals who save hours every day with Medical Scribe.