AI Medical Scribe for
Lung nodule consults, operability workups, and post-resection surveillance — thoracic visits hinge on imaging, PFTs, and hard conversations. Medical Scribe drafts the consult note from the visit, so the documentation keeps pace with a tumor-board-driven practice.
A real example of the documentation Medical Scribe generates for thoracic surgeons — ready before your patient leaves the room.
66M referred with a 2.4cm right upper lobe nodule found on CT for persistent cough. 40 pack-year smoker, quit 3 years ago. No hemoptysis, weight loss, or chest pain. Climbs two flights of stairs without dyspnea. Past history: COPD on tiotropium, hypertension on ramipril 5mg. Prior appendectomy. NKDA. Retired electrician with possible asbestos exposure.
Stereotactic radiotherapy discussed as the non-surgical alternative, including trade-offs in nodal staging. Patient and son's questions on recovery answered — anticipated 2-3 day stay with chest drain. Patient elects surgery; written consent obtained.
Illustrative example. Every note is fully editable, and you control the format — SOAP, DAP, or your own custom template.
A resection candidate's note has to hold the CT and PET findings, biopsy status, FEV1 and DLCO, and the staging picture in one coherent narrative — because anesthesia, oncology, and the tumor board all read from it.
Explaining a lobectomy to a frightened patient — risks, lost lung function, what happens if the nodes are positive — is not a conversation to have while typing. But every element of it belongs in the chart.
New nodules, pre-ops, and surveillance follow-ups stack into the non-operating days. The notes that don't get written in clinic get written after the OR — or drift a week behind.
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.
Thoracic surgery clinic runs a pipeline: the new nodule referral, the operability workup, the pre-op consent visit, and years of post-resection surveillance. Medical Scribe records each encounter and drafts the note before the next patient, so tumor board week doesn’t double as documentation-catch-up week.
Generated notes follow the template’s Subjective, Objective, and Assessment & Plan structure: smoking and exposure history alongside the presenting imaging finding; PET, biopsy, and pulmonary function results in Objective; and a per-condition plan covering the proposed resection, non-surgical alternatives, pre-operative preparation, and the post-operative course — with consent preserved in Additional Notes.
A wrong SUV, a misremembered DLCO, or an invented nodal status in a thoracic note can tip a resection decision. Medical Scribe documents only what was said and observed — no inferred values, no fabricated findings — and every note carries your review and signature before the team acts on it.
Yes. Nodule dimensions, SUV values, FEV1 and DLCO percentages, and stage notation are captured exactly as you state them in the visit, in the Objective section of the built-in Thoracic Surgeon's note — one of 280+ templates, alongside a dedicated cardiothoracic surgeon's note. It never fills in a value you didn't say.
The Assessment & Plan documents the staging impression, the proposed resection, the alternatives discussed (like SBRT), and the referral to tumor board as they were said in clinic — so the MDT reads your actual reasoning, not a reconstruction of it.
The consent discussion is drafted from the conversation itself: the specific complications you named, the alternative treatments offered, and the patient's decision, recorded under Additional Notes. You review and sign before anything enters the chart.
Yes. Record in-person consults or telehealth surveillance reviews on iOS, Android, Web, Apple Watch, or Mac. A 10-minute scan-review call produces a proportionate note. Everything is HIPAA compliant and encrypted in transit and at rest.
Join thousands of healthcare professionals who save hours every day with Medical Scribe.