AI Medical Scribe for
Your patients carry both an injury and its psychiatric aftermath — and your notes have to document the MSE, risk, medications, and recovery-oriented plan for every review. Medical Scribe drafts the full psychiatric note from the session so your attention stays on the patient, not the chart.
A real example of the documentation Medical Scribe generates for rehabilitation psychiatrists — ready before your patient leaves the room.
41M, 8 months post moderate TBI from a motorcycle accident, attending inpatient rehab review. Reports low mood most days, irritability with 'a short fuse I never had,' and poor frustration tolerance in therapy sessions. Sleep fragmented, waking 3-4 times nightly. Denies anhedonia for family visits. PHQ-9 today 14, from 17 four weeks ago.
Denies suicidal ideation, intent, or plan; describes frustration rather than hopelessness. Impulsivity present but not associated with harm to self or others on the ward. Protective factors: engaged in rehab program, supportive wife, future goals around return to part-time work. Overall risk currently low; continue routine monitoring.
Illustrative example. Every note is fully editable, and you control the format — SOAP, DAP, or your own custom template.
TBI, stroke, or spinal cord injury on one axis; depression, PTSD, or psychosis on the other. Each review means documenting the medical and psychiatric picture together — twice the history, one appointment slot.
Suicidality after catastrophic injury, impulsivity after frontal lobe damage, capacity questions around treatment decisions — these assessments need precise, defensible wording every single time.
Your formulation and treatment plan direct psychology, nursing, OT, and community teams. Reviews, care plan updates, and correspondence multiply the writing that follows each appointment.
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.
Ward reviews, family meetings, capacity assessments, outpatient follow-ups after discharge — Medical Scribe records each encounter, in person or by telehealth, and drafts the psychiatric note while you move to the next patient. Collateral from a spouse or the nursing team in the room is captured as part of the same conversation.
The built-in Rehabilitation Psychiatrist’s note template — one of 280+ specialty templates — covers History of Presenting Complaints, Past Medical & Psychiatric History, Medications, Family History, Social History, Mental Status Examination, Risk Assessment, Diagnosis, Treatment Plan, and Safety Plan. A Mental Health Care Plan template is built in too, for structured care planning and review.
After catastrophic injury, risk fluctuates and your wording carries weight. Medical Scribe writes the Risk Assessment and Safety Plan from what the patient actually said about ideation, intent, and protective factors — never from inference — and you review and sign before anything reaches the chart. Your risk record stays yours, and defensible.
Yes. The Rehabilitation Psychiatrist's note template includes structured Mental Status Examination, Risk Assessment, and Safety Plan sections, populated only from what was said and observed in the session — it never invents clinical findings or risk language.
The template separates History of Presenting Complaints, Past Medical & Psychiatric History, Medications, Family History, and Social History, so the injury story and the psychiatric story are each captured where they belong, from one recorded conversation.
The note reflects the actual conversation, including collateral from family or team members present, and you edit before signing. Slowed or dysarthric speech is handled by the same review step: you confirm every clinical statement before it enters the record.
Yes. Medical Scribe is HIPAA compliant, encrypted in transit and at rest, and you control the note. Patients can be informed and consent exactly as they would with a human scribe, and nothing is filed until you sign it.
Join thousands of healthcare professionals who save hours every day with Medical Scribe.