AI scribe: auto-drafted clinical notes
How the AI scribe listens during in-person and telehealth visits, drafts a structured note, and waits for you to sign — never bypasses you.
- Updated
- Updated
- Reading time
- 7 min read
- Tags
- aiscribenotesdocumentation
Listen to your patient Sign the note, not type it
Drafts a structured note formatted to your template. Provider always reads, edits, and signs.
The AI scribe turns the conversation in the room into a structured draft note formatted to your template. It does not replace the rendering provider — every draft sits in your queue until you read, edit, and sign. It just removes the typing.
Enabling the scribe per visit
Maria Lopez · 30-min follow-up
AI scribe
Started 0:14 ago · drafts to your queue
For telehealth, toggle Scribe in the visit room (top-right, next to Recording). For in-person, open the visit on your phone, tap Start scribe, and place the phone face-down on the desk. Both surfaces require explicit consent — the patient hears "this visit is being transcribed by an AI scribe to help with your medical record" and can decline; if they decline, the toggle disables and the visit proceeds as usual. The scribe state is per-visit, so a single declined visit never affects the next one with the same patient.
How the draft is built
During the visit, audio streams to a HIPAA-compliant speech model that produces a transcript with speaker turns. After the visit ends, a clinical model maps the transcript to the sections of your active note template — Subjective, Objective, Assessment, Plan, or whatever your template defines. Diagnoses mentioned by name resolve to ICD-10 candidates; medications mentioned with a dose resolve to RxNorm candidates. Nothing is auto-coded or auto-prescribed — those are picked from a draft, by you.
The review queue
Subjective
Patient reports mood improving over the last two weeks. Sleeping 6 - 7 hours nightly. No active suicidal ideation. Tolerating sertraline 100mg daily; mild dry mouth, no other side effects.
Assessment
Major depressive disorder, single episode, in partial remission. Improvement on current SSRI dose; side effects minimal.
Suggested · confirm before committing
Drafts land in Sidebar → Notes → Drafts within 60 seconds of the visit ending. Each draft shows the patient, the visit time, the template used, and a confidence score. Open the draft and you see the audio transcript in a side rail so you can scrub to the moment any sentence in the note came from. Suggested diagnoses and medication changes appear as chips you confirm before they enter the chart — accept, edit, or remove each one. Edit the prose freely; sign when you are ready.
Guardrails and what the scribe will not do
The scribe will not invent a finding it did not hear. If the patient said "I felt dizzy a couple times" the draft says exactly that — not "intermittent vertigo." Diagnoses, allergies, and medication changes appear as Suggested items the provider must confirm before they are committed to the chart. The scribe will not auto-sign or auto-bill — both require a human action.
Audio, transcript, retention
Audio and transcript are encrypted and stored alongside the visit, available to your care team and the patient (per your release policy) for the life of the chart. Audio is never used to train external models; the scribe uses our private fine-tune of a base model that is contractually prohibited from retention or training on customer data.
When you should not use the scribe
Visits where the patient explicitly declines (always honor that), highly sensitive disclosures the patient asks not to be in the record (you can pause the scribe mid-visit; the gap is logged in the transcript), and visits in noisy environments where transcript quality would be poor enough to be more work to clean up than to type. The toggle is per-visit so opting out one time does not affect the next.
Frequently asked questions
Does the scribe speak Spanish?
What if the draft gets the diagnosis wrong?
Can a scribe (the human kind) use the AI scribe to start their note?
Keep reading
AI Frontdesk: an AI receptionist that answers, books, and triages calls
How the AI receptionist answers your phone 24/7, what it can and cannot do, how warm-transfer to live staff works, and how to read the call log.
Build a note template
How to build a reusable note template with smart fields and signature blocks.
Signing and co-signing notes
Who can primary-sign, when co-sign is required, and how to delegate signing.