AI Medical Scribe for
Recovery work happens in the conversation — cravings, triggers, slips, and wins. Medical Scribe drafts your session note from that conversation, with use status, engagement, and next steps documented the way programs and funders require.
A real example of the documentation Medical Scribe generates for substance abuse counselors — ready before your patient leaves the room.
29M in outpatient treatment for alcohol use disorder, day 47 of sobriety. Reports strong cravings Friday after a work conflict — 'the old routine kicked in' — but called his sponsor instead of drinking. Attended 3 AA meetings this week. Sleep improved to 6-7 hours. Naltrexone 50mg daily, no missed doses, no side effects reported.
On time, appropriately dressed, engaged throughout. Speech and affect congruent with content; brightened when describing the sponsor call. No signs of intoxication or withdrawal observed. Completed craving log for 6 of 7 days.
Sustained abstinence with an effectively managed high-risk situation — first successful real-world use of the coping plan since intake. Work stress remains the primary trigger. Engagement and adherence high; risk of return to use assessed as moderate and trending down.
Illustrative example. Every note is fully editable, and you control the format — SOAP, DAP, or your own custom template.
Treatment programs, courts, and funders expect each session documented: current use status, cravings and triggers, engagement, progress toward the treatment plan, and next steps. Thin notes put continued funding — and sometimes the client's program standing — at risk.
Clients disclosing a slip or a craving watch how you react. A counselor typing mid-disclosure reads as distraction or judgment, and honest reporting — the raw material of recovery work — dries up.
A full day of sessions can mean a dozen notes, each needing enough clinical detail to be useful next week. They get written after hours, when the specifics of who said what have already faded.
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.
Recovery counseling turns on moments — the admitted slip, the craving described in detail, the first successful sponsor call. Medical Scribe records the session (in person or telehealth) and drafts the note afterward, so you’re watching the client during the disclosure instead of documenting it, and the session’s specifics survive to the chart intact.
The Substance Abuse Counselor’s note structures each session into Subjective, Objective, Assessment, and Plan — substance use status and cravings, your observations including any signs of intoxication or withdrawal, progress toward recovery goals and barriers to them, and next steps with referrals. The Counselor’s Note template adds interventions and risk management for programs that require them.
An addiction treatment chart can affect employment, custody, and legal standing. Medical Scribe documents only what was said and observed in session — it never invents clinical impressions — and every note passes through your review and signature before filing, with encryption in transit and at rest throughout.
The same consent practices your program already uses for records apply here: the client is informed and agrees, and the recording exists solely to draft your note. Medical Scribe is HIPAA compliant and encrypted in transit and at rest, and you control what enters the record — nothing is filed until you review and sign.
The note reflects what was actually discussed — use status, triggers, coping responses, engagement — in clinical language drawn from the session. The built-in Substance Abuse Counselor's note captures cravings, recent episodes, and progress toward recovery goals as clinical data, and you edit the framing before signing.
Yes. Alongside the Substance Abuse Counselor's note (Subjective, Objective, Assessment, Plan), the 280+ built-in templates include a Counselor's Note with dedicated sections for session content, obstacles and progress, interventions, and risk assessment. Custom formats for a specific program's paperwork take minutes.
Yes — telehealth and in-person sessions both, with apps for iOS, Android, Web, Apple Watch, and Mac. A phone-based check-in generates the same structured note as an office session.
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