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ClinicalScribe Documentation

Everything you need to capture clinical encounters, generate structured SOAP notes, and export signed, audit-ready clinical documents.

Quick StartSOAP WorkflowPDF & SigningEHR FilingSecurity

1. Quick Start: Ambient Recording

ClinicalScribe listens to clinical encounters in real time so clinicians can focus directly on the patient without looking at a computer screen.

  1. Start Recording: Navigate to the Transcription dashboard and select your microphone. Click Start Recording.
  2. Automatic Chunking: Long sessions are automatically split into 15-minute segments to avoid audio data loss or upload timeouts.
  3. Stop & Review: Click Stop Recording. Your speech is transcribed into clean clinical text with phonetic normalization for medical terms.
  4. Generate SOAP: Click Generate SOAP Note to produce structured Subjective, Objective, Assessment, and Plan documentation in seconds.

2. SOAP Documentation Workflow

Notes adhere to the clinical standard SOAP architecture:

Subjective (S)

Chief complaint, history of present illness (HPI), patient-reported symptoms, and medical history.

Objective (O)

Vital signs, physical examination findings, lab/imaging results, and measurable clinical metrics.

Assessment (A)

Primary diagnoses, differential diagnoses, clinical impression, and patient progress evaluation.

Plan (P)

Medications, diagnostic workup, therapy, patient instructions, follow-up timelines, and referrals.

Autosave Protection: When using the manual entry tab, your progress is continuously autosaved to your local browser session. Reloading never loses your clinical draft.

3. PDF Generation & Clinical Signatures

Clinical notes can be converted into formatted PDF encounter summaries:

  • Interactive Signature Canvas: Draw your signature directly with a mouse, trackpad, or stylus.
  • Electronic Attestation: If no drawn signature is added, typing your clinician name produces a clean legal electronic verification line.
  • Clean Output: Formatted without intrusive watermarks, fact-distorting machine translations, or stray markup artifacts.
  • Secure Cloud Storage: Generated PDFs are saved with authenticated access in encrypted cloud storage for your practice.

4. EHR Filing & Text Export

ClinicalScribe produces export-ready notes your staff files in minutes into any EHR or practice management system.

One-Click Clipboard Copy

Copy individual SOAP sections or the entire note with a single click. A small "Copied" toast confirms the text is ready to paste into Epic, Cerner, AthenaHealth, or any clinical software.

Text (.txt) Export

Export complete encounter notes as universal raw text files for easy attachment to electronic health record records or archival storage.

5. Security & Data Privacy

Protecting sensitive health records is our core architectural priority:

256-bit Encryption

TLS 1.2+ encryption for all data in transit, and AES-256 encryption for all data at rest.

Practice Isolation

Multi-tenant isolation ensures your clinical encounters and notes are accessible only by your authenticated clinic staff.

Clinical Use & Compliance

Clinical use involving protected health information requires appropriate agreements and data-retention settings with each service provider.

Need personalized assistance?

Our clinical support team is here to help you get the most out of ClinicalScribe.

Contact SupportView Beta Plans