*Note examples are illustrative representations based on common AI documentation patterns. “Typical AI Scribe” represents composite characteristics of standard tools and does not depict any specific product. Patient scenarios are entirely fictional. Clinical notes should always be reviewed by a licensed provider.
AI Medical Scribe Note Quality Comparison
Scribeable produces clinically enriched notes with integrated risk calculators (HEART Score, CHA₂DS₂-VASc, Wells PE, PHQ-9, Caprini VTE), automated billing code optimization (E&M levels, HCC/RAF capture, CPT codes), dangerous diagnosis exclusion documentation, evidence-based prescribing citations, CMS compliance for operative reports, HEDIS care gap tracking, and MIPS quality measure documentation. Typical AI scribes produce basic notes without these advanced clinical features.
ED Chest Pain: 62-year-old male presenting with substernal chest pressure, diaphoresis, and exertional dyspnea
HPI: 62 y/o male presents with 2 hours of substernal chest pressure, rated 8/10, radiating to left arm and jaw. Onset during exertion (climbing stairs). Associated with diaphoresis and exertional dyspnea. Pressure-like quality, unrelieved by rest. No pleuritic component, no positional variation, no reproducibility with palpation. Risk factors: HTN (10 years), DM2 (8 years), hyperlipidemia, 30-pack-year smoking history (quit 5 years ago), family history of MI (father at age 58). Current medications: lisinopril 20mg daily, metformin 1000mg BID, atorvastatin 40mg daily. Denies cocaine use, recent immobilization, or prior VTE.
Assessment & Plan: 1. Acute Chest Pain — High-risk presentation
HEART Score: 7 (High Risk)
- History: moderately suspicious (2), EKG: non-specific ST changes (1), Age: >65 (2), Risk factors: ≥3 (2), Troponin: pending initial (0)
- Risk stratification: >12% 6-week MACE event rate → full ACS workup
- Serial troponins q3h, 12-lead EKG (initial + repeat at 60 min)
- ASA 325mg PO administered, heparin drip per ACS protocol
- Cardiology consulted for probable cath lab activation
Dangerous Diagnosis Exclusion:
- STEMI: No ST elevation on initial EKG — serial monitoring
- Aortic dissection: No tearing quality, no pulse differential, no mediastinal widening on CXR
- PE: Low pretest probability (Wells PE: 1.5) — no immobilization, no prior VTE, no hemoptysis
2. Hypertension — BP 168/94 on arrival, improved to 142/88 post-NTG
- Continue home lisinopril, recheck prior to disposition
3. DM2 — Glucose 186 on arrival
- Hold metformin (contrast exposure risk), sliding scale insulin PRN
Cardiology Consult: 71-year-old female with new-onset atrial fibrillation and decompensated heart failure
HPI: 71 y/o female with known HFrEF (EF 35% on TTE 6 months ago), HTN, DM2, and CKD Stage 3a (baseline Cr 1.4), consulted for new-onset atrial fibrillation with RVR. Progressive exertional dyspnea (NYHA II → IV over 2 weeks), 3-pillow orthopnea (new), PND, and 4+ pitting edema to knees bilaterally. Weight gain of 8 lbs over 2 weeks. Triggers explored: dietary indiscretion (holiday meals), medication non-adherence (ran out of furosemide 10 days ago). No prior AF history, no palpitations previously. Denies chest pain, syncope, or presyncope.
Assessment & Plan: Reason for Consult: New-onset atrial fibrillation with RVR in setting of acute decompensated HFrEF.
Requesting Service: Internal Medicine (Dr. Patel)
1. New-onset Atrial Fibrillation with RVR
CHA₂DS₂-VASc Score: 5 (Female sex, age ≥75, HTN, DM, HF)
- Stroke risk: 6.7%/year → strong anticoagulation indication
- Rate control: avoid diltiazem (negative inotropy in HFrEF) → amiodarone 150mg IV bolus then 1mg/min × 6h
- Anticoagulation: apixaban 5mg BID (preferred over warfarin given age + fall risk)
- TEE prior to any cardioversion attempt if AF duration uncertain
- HAS-BLED: 2 (HTN, age) — acceptable bleeding risk
2. Acute Decompensated Heart Failure (ADHF)
NYHA Functional Class: IV (dyspnea at rest)
- IV furosemide 80mg BID (2.5× home oral dose), net negative 1-1.5L/day
- Carvedilol held (acute decompensation), restart when euvolemic
- Add sacubitril/valsartan when stable (PARADIGM-HF indication: EF ≤40% on ACEi)
- BNP trend: 1,840 → monitor for response to diuresis
3. CKD Stage 3a — Cr 1.4 (baseline), monitor with aggressive diuresis
- KDIGO risk: moderate — monitor Cr/K daily with diuresis
Operative Note: Right total knee arthroplasty in 68-year-old male with severe tricompartmental osteoarthritis
Operative Note: Preoperative Diagnosis: Right knee severe tricompartmental osteoarthritis (Kellgren-Lawrence Grade IV)
Postoperative Diagnosis: Same
Procedure: Right total knee arthroplasty
Surgeon: Dr. James Morrison (attending — present and scrubbed for entire case)
Assistant: Dr. Chen (PGY-4)
Anesthesia: Spinal with sedation (Dr. Rivera)
Implants: Smith & Nephew Legion CR, Size 5 femoral / Size 4 tibial / 10mm poly insert
EBL: 150 mL
Tourniquet Time: 62 minutes (pneumatic, 275 mmHg)
Specimens: Femoral and tibial bone cuts — to pathology
Complications: None
Findings: Severe tricompartmental degenerative changes with exposed subchondral bone medially, grade III chondromalacia laterally, intact PCL
Post-Operative Plan: 1. Weight Bearing: WBAT right LE with front-wheeled walker
2. DVT Prophylaxis: Enoxaparin 40mg SQ daily × 14 days + mechanical (SCDs while inpatient)
3. Pain: Multimodal — scheduled acetaminophen 1g Q6h, meloxicam 15mg daily, tramadol 50mg Q6h PRN (max 14 days)
4. Antibiotics: Ancef 2g IV × 24h post-op
5. PT: Initiate POD0 PM — CPM machine, active/passive ROM, gait training
6. Follow-up: 2 weeks (staple removal + wound check), 6 weeks (X-ray + ROM assessment)
7. VTE Risk: Caprini Score 7 (High Risk) — extended pharmacologic prophylaxis indicated
Primary Care: 55-year-old female Medicare Advantage patient with DM2, HTN, depression, and overdue preventive care
HPI: 55 y/o female Medicare Advantage patient presenting for chronic disease management follow-up. Last visit 3 months ago.
Diabetes (DM2, 8 years): A1c 8.2% (up from 7.6%), reports adherence but dietary indiscretion during holidays. Home glucose logs show fasting 140-180 range. No hypoglycemic episodes. Denies polyuria, polydipsia, vision changes, or foot numbness. Last diabetic eye exam: 14 months ago (overdue). Last podiatry visit: never.
Hypertension (12 years): Home BP readings averaging 135-145/85-90. Taking lisinopril 20mg daily consistently.
Depression (MDD, recurrent): PHQ-9 score today: 14 (moderately severe). Persistent low mood, anhedonia, poor sleep (initial insomnia), decreased concentration. On sertraline 50mg × 6 months with partial response. Denies SI/HI, denies alcohol or substance use. Columbia Suicide Severity: negative for ideation and behavior.
Assessment & Plan: 1. DM2, Uncontrolled (A1c 8.2%) — HCC 19
- Add empagliflozin 10mg daily (SGLT2i — CV and renal benefit, EMPA-REG OUTCOME indication)
- Continue metformin 500mg BID (not escalating given GI intolerance history)
- Diabetic eye exam referral (overdue 2 months — HEDIS measure)
- Podiatry referral for initial foot exam
- Recheck A1c in 3 months, target <7%
2. Hypertension, Suboptimally Controlled — HCC (when with CKD/DM)
- BP today 138/86 — above target of <130/80 (ACC/AHA for DM patients)
- Increase lisinopril to 40mg daily
- Home BP log review in 4 weeks
3. Major Depressive Disorder, Recurrent, Moderate — HCC 59
- PHQ-9: 14 (moderately severe) — partial response to sertraline 50mg
- Increase sertraline to 100mg daily
- Safety plan reviewed, crisis line provided (988)
- Follow-up in 4 weeks, recheck PHQ-9
- If inadequate response → consider augmentation or psychiatry referral
4. Preventive Care Gaps Addressed:
- Mammogram ordered (last: 26 months ago — HEDIS BCS measure)
- Colonoscopy referral (age 55, average risk, never screened — HEDIS COL)
- Tobacco screening: former smoker, quit 3 years — MIPS measure 226
- Annual flu vaccine administered today — MIPS measure 110