Set your normal exam once
Scott Kohlhepp, DO
Founder & CEO
Nobody narrates a normal exam out loud. You listen to the lungs, you look at the skin, you say something about the one thing that was abnormal, and you move on. That leaves an AI scribe with two bad options: leave the exam half empty, or write findings nobody said. Scribeable doesn't do the second one, so for a long time you got the first.
Now you can tell it what your normal exam looks like. In the web cockpit, go to Settings, then Preferences, then Normal exam defaults, and write your own or start from a specialty default. There are defaults for internal medicine, family medicine, emergency medicine, cardiology, psychiatry, and general practice, plus focused ones for dermatology, ophthalmology, ENT, podiatry, orthopedics, neurology, PM&R, dental, urology, and OB/GYN.
How it lands in the note
- Only systems nobody talked about. If anything was said about a system during the visit, by you or the patient, that system is written from the visit. The part of your normal line that the visit contradicts is removed, and the finding is added.
- Depending on the note, it goes in or it waits. Once you have made the exam your own, on many notes it is written in with the note, whether you recorded on the web or on iPhone, and you review it with the rest of the note before you sign. On other notes it is offered in the web cockpit as a pending block you tap to apply. It is not used for psychiatric evaluations, ED triage notes, or case reports.
- A specialty default you haven't changed always waits for your tap. It appears as a pending block, and nothing is added until you apply it. In that block, psychiatric risk has to be confirmed separately and suicidal and homicidal ideation are never filled in for you.
- Sensitive exams are never filled. Pelvic, rectal, breast, and genitourinary exams are excluded.
For a focused-exam template, you turn it on once, and the dialog warns you that it will add a full normal exam to a focused note. Empty sections also get an Insert my default button if you'd rather fill one section yourself.
You set your normal exam in the web cockpit. Start the 14-day trial at scribeable.ai, or see the pricing page for plans.
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