AI Medical Scribe for
Whether you practice CBT, EMDR, family systems, or plain good listening, the note after each session is the tax on doing therapy. Medical Scribe drafts intake write-ups and progress notes from the session itself — so 6pm doesn't mean four unwritten notes.
A real example of the documentation Medical Scribe generates for therapists — ready before your patient leaves the room.
27F self-referred for persistent worry and difficulty relaxing, worsening over 8 months since a promotion to team lead. Reports muscle tension, irritability, and difficulty concentrating in meetings. GAD-7 completed at intake: 14, moderate anxiety.
Denies suicidal ideation, intent, or plan, past and present. No self-harm history. No homicidal ideation. No impulsivity or risk-taking concerns identified. Risk assessed as low; no safety plan indicated at this time.
Well-groomed, cooperative, good eye contact. Speech normal rate and volume. Mood 'stretched thin'; affect anxious but full range. Thought process linear. No perceptual disturbance. Insight and judgment good.
Illustrative example. Every note is fully editable, and you control the format — SOAP, DAP, or your own custom template.
Six to eight sessions a day, each needing a progress note with presentation, interventions, response, and plan. Skip a day and the backlog compounds; write during sessions and the work suffers.
A new client means presenting problems, history, risk screening, mental status, and a treatment plan with measurable goals — often the difference between reimbursed care and a denied claim.
When a client mentions suicidal thoughts in minute 38, your documentation of what was said, what you assessed, and what you did becomes the most important paragraph in the chart.
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.
Therapists aren’t one discipline — the same waiting room serves CBT, psychodynamic work, couples sessions, and grief counseling. Medical Scribe records the session (office or teletherapy) and drafts a note matched to the work: a full clinical interview write-up for intakes, a concise progress note for session 14. You stay in the room; the note comes after.
Intake notes follow the template’s Clinical Interview structure — presenting problems, current functioning across sleep, work, and relationships, history, risk assessment, mental state exam, and clinical formulation — flowing into a Treatment Plan with DSM-5-TR diagnoses, goals, and outcome measures. Ongoing sessions draw on the Psychotherapy Note and Psychology Progress Note formats instead.
The paragraph that matters most in a therapy chart is the one about safety. Medical Scribe documents risk exactly as it was explored in session — the ideation asked about, the answers given, the plan made — and never generates findings that weren’t said. Nothing is filed until you’ve reviewed and signed it.
Progress notes — the official-record documentation of presentation, interventions, and plan that supports treatment and billing. Your private psychotherapy notes (process notes) stay separate, exactly as HIPAA intends. Medical Scribe drafts the progress note; what you keep for yourself remains yours.
The 280+ built-in templates cover the breadth of talk therapy: the Therapist's note with full clinical interview and DSM-5-TR-keyed treatment plan, a Psychotherapy Note, a Psychology Progress Note, a Mental Health Care Plan, and dedicated formats for marriage and family therapists, CBT practitioners, and grief counselors. DAP and SOAP formats are supported, and custom templates take minutes.
The Risk Assessment section documents what was actually said about suicidal or homicidal ideation, self-harm, and your assessment and response — never a boilerplate 'denies SI/HI' the client didn't say. You review that language carefully before signing, as you would any risk documentation.
With informed consent, yes — the same consent conversation you'd have before any recording. Sessions are encrypted in transit and at rest, Medical Scribe is HIPAA compliant, and the recording's only job is drafting a note that you review, edit, and sign.
Join thousands of healthcare professionals who save hours every day with Medical Scribe.