AI Medical Scribe for
You can't chart with sterile gloves on. Medical Scribe captures perioperative documentation — counts, positioning, specimens, and how the patient did — so the record is finished when the case is.
A real example of the documentation Medical Scribe generates for scrub nurses — ready before your patient leaves the room.
58F admitted for elective laparoscopic cholecystectomy for symptomatic cholelithiasis. Verbalized understanding of the procedure; expressed anxiety about anesthesia, reassurance provided. NKDA. NPO since midnight confirmed.
Patient tolerated procedure well. Skin integrity intact at pressure points on transfer to stretcher. No breaks in sterile technique observed. Counts correct at close.
Transferred to PACU with verbal handoff report at 10:35 — procedure summary, count status, specimen disposition, and lines communicated to receiving nurse.
Illustrative example. Every note is fully editable, and you control the format — SOAP, DAP, or your own custom template.
Room turnover pressure means intraoperative details — prep, positioning, irrigation, implants — get reconstructed at the end of the case or the end of the day, when the next patient is already waiting.
Retained-item claims come down to what the record says about your counts. 'Counts correct x2' has to be documented precisely, every case, along with every specimen that left the field.
Skin assessment, positioning and padding, prep solution, time-out, sterile technique — the same required elements case after case, and any one missing is a gap surveyors will find.
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.
A scrub nurse’s documentation spans the whole case: pre-op assessment, time-out, intraoperative events, and handoff. Medical Scribe records those conversations and your spoken observations — before the case, at the field, and at debrief — then drafts the perioperative note so you’re not reconstructing positioning and prep details during turnover.
The built-in Scrub Nurse’s note template — one of 280+ specialty templates — structures the record into Patient Information, Subjective, Objective, Assessment, Plan, Interventions, Evaluation, and Plan for Continuing Care. Positioning, prep, counts, specimens, and the PACU handoff each land under their proper heading, ready for review.
When a case is questioned months later, the nurse’s contemporaneous documentation is the evidence. Because Medical Scribe only documents what was actually said and observed — never an assumed ‘counts correct’ — your record reflects the verification you really performed, signed by you the day of surgery.
You record where the talking happens: the pre-op assessment, the team time-out, spoken count confirmations, and your post-case debrief or handoff. Speak your observations — 'counts correct times two' — and the note captures them verbatim into the right sections. Apps for iOS, Android, Web, Apple Watch, and Mac.
The Scrub Nurse's note template has dedicated Interventions and Evaluation sections where count status, specimen labeling, and sterile-technique observations are recorded exactly as stated — and only as stated. It never fills in a count you didn't verbalize.
Yes. Each case generates its own standalone note from its own recording, so a 40-minute lap chole and a 4-hour revision each get documentation proportionate to what happened — reviewed and signed by you before filing.
Medical Scribe is HIPAA compliant with encryption in transit and at rest. Recordings are processed securely, and nothing enters the record until you approve it.
Join thousands of healthcare professionals who save hours every day with Medical Scribe.