AI Medical Scribe for
Between spirometry numbers, smoking histories, inhaler regimens, and a full review of systems, a respiratory consult letter takes longer to write than the consult took to do. Medical Scribe drafts the complete note — ROS and all — from the visit conversation.
A real example of the documentation Medical Scribe generates for respiratory physicians — ready before your patient leaves the room.
63M referred for follow-up of COPD, 6 weeks after an exacerbation requiring oral prednisolone and amoxicillin. Reports dyspnea on inclines and stairs (mMRC grade 2), morning cough with scant white sputum, no hemoptysis. Two exacerbations in the past 12 months, none requiring admission. Ex-smoker, quit 3 years ago, 40 pack-years. Current medications: tiotropium 18mcg inhaled daily, salbutamol PRN (using 2-3 times weekly). No known allergies.
Comfortable at rest, SpO2 94% on room air, RR 16, BP 134/82. Chest: reduced breath sounds at both bases with prolonged expiratory phase; no crackles or focal wheeze. No cyanosis or clubbing. Trace bilateral pitting ankle edema. JVP not elevated.
1. COPD, GOLD 3 group E — two exacerbations in 12 months with eosinophils above 300: escalate to triple therapy, switching tiotropium to a single-inhaler LAMA/LABA/ICS; inhaler technique checked and corrected today. Pulmonary rehabilitation referral placed. Influenza and pneumococcal vaccination status confirmed up to date. 2. Evening ankle edema — consider echocardiogram if persists; review at next visit. Repeat spirometry and review in 3 months; letter to GP dictated.
Illustrative example. Every note is fully editable, and you control the format — SOAP, DAP, or your own custom template.
FEV1, FVC, ratios, DLCO, sats on exertion, pack-years — respiratory assessment is quantitative, and every value has to land in the note correctly alongside a detailed symptom history.
A proper consult documents constitutional, cardiovascular, respiratory, and a dozen other systems. Capturing what the patient actually endorsed — across all of them — is tedious to reconstruct after clinic.
COPD, asthma, ILD, and OSA patients return for decades. Each review must document trajectory — exacerbation counts, therapy escalations, lung function trends — clearly enough for the GP letter that follows.
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.
New consults for chronic cough or abnormal imaging, COPD and asthma reviews, ILD surveillance visits, sleep clinic follow-ups — Medical Scribe records the encounter, in rooms or over telehealth, and drafts the full consult note while you call in the next patient. The post-clinic dictation pile stops accumulating.
The built-in Respiratory Physician’s note template — one of 280+ specialty templates — structures each visit into Subjective (including smoking and family history), a full Review of Systems, and Objective sections for Examination, Investigations, and an issue-numbered Impression & Plan with differentials, planned tests, treatment, and referrals. It writes the way respiratory consults are actually laid out.
An FEV1 of 48% predicted escalates therapy; a misheard one misleads every clinician downstream. Medical Scribe records only the values, findings, and plans actually voiced in the consult — it never invents or infers a result — and the note reaches the chart only after your review and signature.
Yes. The Respiratory Physician's note template includes a structured Review of Systems and an Investigations section, and the FEV1, ratios, and sats you state are transcribed exactly as spoken. Only systems and values you actually mention appear — nothing is auto-filled as 'normal.'
The generated note is organized as a consult — history, ROS, examination, investigations, and an issue-by-issue Impression & Plan — so the content of your GP letter is drafted the moment the patient leaves. You edit and sign before anything is sent or filed.
The note is built from the whole visit conversation, including your own summarizing statements, and it works in 57 languages. You review everything before signing, so nothing enters the record on transcription alone.
Yes — it records in-person and telehealth visits on iOS, Android, Web, Apple Watch, and Mac, and it's HIPAA compliant with encryption in transit and at rest. Long new-patient consults and brief follow-ups each produce an appropriately sized note.
Join thousands of healthcare professionals who save hours every day with Medical Scribe.