Internal Medicine
AI Medical Scribe for Hospitalists & Internists
Comprehensive clinical documentation for inpatient and outpatient internal medicine. From complex admission H&Ps to daily progress notes and detailed discharge summaries.
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Documentation Challenges in Internal Medicine
Complex multi-problem patients requiring detailed documentation
Time pressure from high patient volumes
Balancing thorough documentation with patient face-time
Capturing all billable diagnoses for proper reimbursement
Coordinating care across multiple consultants
Note Types for Internal Medicine
Purpose-built templates for every encounter type
Admission H&P
Comprehensive history and physical for new admissions with full problem list
Daily Progress Notes
SOAP-format notes with assessment and plan for each active problem
Discharge Summaries
Complete discharge documentation with medication reconciliation
Consultation Notes
Specialty consultation responses with recommendations
Key Features for Internal Medicine
Built specifically for your workflow
Multi-Problem Management
Automatically organizes notes by problem with separate A&P for each
Auto ICD-10 Coding
Captures all relevant diagnoses including HCC codes for risk adjustment
Complete Admission Notes
Multi-problem H&Ps drafted from one recording, with an A&P per problem
HIPAA Compliant
Full HIPAA compliance with signed BAA and encryption
Rounding Mode
Multi-patient encounter tracking for efficient hospital rounding workflows
Common Internal Medicine Conditions
Common Internal Medicine Procedures
Office Visit - Established Patient - Low Complexity
CPT: 99213
Office Visit - Established Patient - Moderate Complexity
CPT: 99214
Office Visit - Established Patient - High Complexity
CPT: 99215
Office Visit - New Patient - Low Complexity
CPT: 99203
Office Visit - New Patient - Moderate Complexity
CPT: 99204
Calculators that can activate in Internal Medicine
Registry entries whose specialty scope includes Internal Medicine. Each page lists the inputs the note needs, the scoring criteria, the interpretation bands and the cited sources.
- 4Ts Score for Heparin-Induced ThrombocytopeniaEstimates pre-test probability of heparin-induced thrombocytopenia (HIT) to guide confirmatory testing and management
- ABCD2 ScoreEstimates short-term stroke risk after TIA
- ACR TI-RADS (Thyroid Imaging Reporting and Data System)Standardizes thyroid nodule risk stratification on ultrasound to guide biopsy decisions
- Adult ADHD Self-Report Scale (ASRS)Screens for adult ADHD using a validated 6-item Part A screener
- ARISCAT ScorePredicts postoperative pulmonary complications to guide perioperative respiratory optimization
- AUDIT-CBrief alcohol screening tool (USPSTF-recommended) for hazardous drinking
- Berlin Questionnaire for OSAScreens for obstructive sleep apnea risk to guide polysomnography referral
- BI-RADS (Breast Imaging Reporting and Data System)Standardizes breast imaging assessment and management recommendations to ensure consistent reporting and follow-up
- BISAP ScorePredicts mortality in acute pancreatitis within 24 hours of presentation using readily available parameters
- BODE IndexPredicts mortality in COPD patients using body mass index, airflow obstruction, dyspnea, and exercise capacity
- Body Mass Index (BMI)Classifies weight status relative to height to guide nutritional counseling, surgical risk, and metabolic assessment
- Body Surface Area (Mosteller)Calculates body surface area for chemotherapy dosing, cardiac index, and renal function estimation
- C-SSRS (Columbia Suicide Severity Rating Scale)Structured assessment of suicidal ideation and behavior for risk stratification
- CAGE QuestionsScreens for alcohol use disorder
- Calcium Corrected for AlbuminAdjusts total calcium for hypoalbuminemia to determine true calcium status
- Calculated Serum OsmolalityEstimates serum osmolality from basic metabolic panel to evaluate osmolar gap and dysnatremia
- Caprini VTE Risk ScoreStratifies VTE risk in surgical patients for prophylaxis decisions
- CHA2DS2-VASc ScoreStratifies stroke risk in non-valvular atrial fibrillation to guide anticoagulation decisions
- Child-Pugh ScoreClassifies cirrhosis severity and prognosis
- CIWA-ArObjectifies alcohol withdrawal severity for symptom-triggered treatment
- CKD-EPI GFREstimates glomerular filtration rate for CKD staging
- Clinical Frailty Scale (Rockwood)Categorizes frailty status to guide treatment intensity, surgical candidacy, and prognostication in elderly patients
- Cockcroft-Gault Creatinine ClearanceEstimates creatinine clearance for renal drug dosing adjustments, particularly DOACs and renally-cleared medications
- COPD Assessment Test (CAT)Quantifies COPD symptom impact on daily life for treatment monitoring and GOLD group classification
- Corrected QT Interval (QTc)Corrects QT interval for heart rate to identify clinically significant QT prolongation and torsades risk
- CURB-65 ScoreEstimates pneumonia mortality and guides disposition
- DIRE Score (Diagnosis, Intractability, Risk, Efficacy)Predicts suitability for long-term opioid therapy in chronic non-cancer pain
- Drug Abuse Screening Test-10 (DAST-10)Screens for drug use problems and quantifies severity of drug-related consequences
- Duke Activity Status Index (DASI)Estimates functional capacity in METs for perioperative cardiac risk assessment
- Duke Treadmill ScorePredicts prognosis from exercise treadmill testing and identifies low-, moderate-, and high-risk patients
- ETDRS Diabetic Retinopathy Severity ScaleStandardizes diabetic retinopathy severity grading to guide ophthalmologic management and treatment timing
- FIB-4 IndexNon-invasive assessment of liver fibrosis
- Fleischner Society Criteria for Pulmonary Nodule Follow-upProvides evidence-based follow-up recommendations for incidental pulmonary nodules based on size, type, and patient risk factors
- Fontaine Classification for PADStages peripheral arterial disease severity using clinical presentation
- Fractional Excretion of Sodium (FENa)Differentiates prerenal from intrinsic renal failure
- Free Water DeficitEstimates free water needed to correct hypernatremia based on total body water and measured sodium
- GAD-7Measures anxiety severity and screens for anxiety disorders
- Glasgow Alcoholic Hepatitis ScoreAlternative severity score for alcoholic hepatitis that identifies patients likely to benefit from corticosteroid therapy
- Glasgow Coma Scale (GCS)Assesses impaired consciousness and coma severity
- Glasgow-Blatchford Bleeding ScoreIdentifies low-risk upper GI bleed patients safe for outpatient management
- Glucocorticoid Equivalence CalculatorConverts between glucocorticoids using equipotent dose equivalency for taper planning and medication switches
- GOLD COPD ClassificationClassifies COPD severity by spirometry and symptom burden using the GOLD 2024 framework for treatment guidance
- GRACE ACS Risk ScorePredicts in-hospital and 6-month mortality in acute coronary syndrome patients using the GRACE 2.0 simplified model
- Harvey-Bradshaw IndexSimplified assessment of Crohn disease activity for treatment monitoring and clinical decisions
- HAS-BLED ScoreEstimates 1-year major bleeding risk in AF patients on anticoagulation
- HEART ScorePredicts 6-week risk of major adverse cardiac events in ED chest pain patients
- Hinchey ClassificationStages complicated diverticulitis severity by degree of peritoneal contamination to guide surgical vs medical management
- Hoehn and Yahr ScaleStages Parkinson's disease severity based on motor symptom distribution and balance impairment
- Ideal Body Weight (Devine)Calculates ideal body weight for lung-protective ventilation tidal volume and medication dosing
- Insomnia Severity Index (ISI)Quantifies insomnia severity for diagnosis and treatment monitoring
- KDIGO AKI StagingStages acute kidney injury severity to guide management and prognosis
- LDL Calculated (Friedewald Equation)Calculates LDL cholesterol from standard lipid panel when direct LDL is unavailable
- Light's CriteriaDifferentiates transudative from exudative pleural effusions to guide diagnostic workup
- Lille ModelPredicts response to corticosteroid therapy at day 7 in severe alcoholic hepatitis; identifies non-responders who should stop steroids
- Maddrey's Discriminant FunctionQuantifies severity of alcoholic hepatitis and identifies patients who may benefit from corticosteroid therapy
- Maintenance IV Fluids (4-2-1 Rule)Calculates hourly maintenance IV fluid rate using the Holliday-Segar method based on body weight
- Mayo Score for Ulcerative ColitisAssesses disease activity in ulcerative colitis for treatment decisions and clinical trial endpoints
- Mean Arterial Pressure (MAP)Calculates mean arterial pressure to assess end-organ perfusion adequacy
- MELD-Na ScoreQuantifies end-stage liver disease severity for transplant prioritization
- Modified Centor / McIsaac ScoreEstimates likelihood of group A streptococcal pharyngitis to guide testing and antibiotic decisions
- Modified Duke CriteriaClassifies likelihood of infective endocarditis based on clinical, microbiological, and echocardiographic findings
- Modified Medical Research Council Dyspnea ScaleGrades dyspnea severity for COPD symptom assessment and treatment decisions
- Modified Rankin Scale (mRS)Measures degree of disability and dependence after stroke or neurological event
- Mood Disorder Questionnaire (MDQ)Screens for bipolar spectrum disorders in patients presenting with mood symptoms
- Morphine Milligram Equivalents (MME)Converts opioid prescriptions to standardized morphine equivalents to assess cumulative opioid burden and overdose risk
- National Early Warning Score 2 (NEWS2)Standardized early warning score to detect clinical deterioration in hospitalized patients and guide escalation of care
- NYHA Functional ClassificationClassifies heart failure severity by functional limitation to guide treatment escalation and prognostication
- Opioid Risk Tool (ORT)Predicts risk of opioid aberrant behaviors before initiating opioid therapy
- Padua VTE Risk Assessment ScoreStratifies VTE risk in hospitalized medical patients to guide thromboprophylaxis decisions
- PCL-5 (PTSD Checklist for DSM-5)Screens for PTSD and monitors symptom severity over time
- PEG Scale (Pain, Enjoyment, General Activity)Ultra-brief pain screening tool assessing pain intensity and functional impact
- PERC RuleRules out PE when all criteria absent AND pre-test probability <=15%
- PHQ-9Assesses depression severity and screens for MDD
- PLASMIC ScorePredicts probability of severe ADAMTS13 deficiency (TTP) in adults with thrombotic microangiopathy to guide urgent plasma exchange
- PREVENT 10-Year Total CVD Risk (AHA)Estimates 10-year risk of total cardiovascular disease (atherosclerotic CVD plus heart failure) to guide primary-prevention decisions. Supersedes the Pooled Cohort Equations and does NOT use race.
- PSI/PORT ScoreStratifies pneumonia severity into risk classes to guide site-of-care decisions (outpatient vs inpatient vs ICU)
- qSOFA ScoreIdentifies non-ICU patients with infection at high mortality risk
- Ranson's CriteriaEstimates pancreatitis severity and mortality based on admission and 48-hour parameters
- Revised Cardiac Risk Index (RCRI)Estimates perioperative cardiac risk for non-cardiac surgery
- Revised Geneva ScoreClinical prediction rule for estimating pre-test probability of pulmonary embolism
- Rockall ScorePredicts rebleeding and mortality risk after upper GI bleeding based on pre- and post-endoscopy factors
- Rutherford Classification for PADClassifies severity of peripheral arterial disease for treatment planning
- Serum Anion GapEvaluates metabolic acidosis etiology
- Sgarbossa CriteriaIdentifies acute MI in patients with left bundle branch block or ventricular paced rhythm
- SHIM/IIEF-5 (Sexual Health Inventory for Men)Screens for and quantifies erectile dysfunction severity to guide treatment approach
- SIRS Criteria (Systemic Inflammatory Response Syndrome)Identifies systemic inflammatory response to guide early sepsis recognition and management
- SOAPP-R (Screener and Opioid Assessment for Patients with Pain-Revised)Screens for risk of aberrant medication-related behaviors in chronic pain patients
- Sodium Corrected for HyperglycemiaCorrects measured sodium for glucose-induced dilutional effect to reveal true sodium status
- Sodium Correction RateMonitors sodium correction rate in hyponatremia to prevent osmotic demyelination syndrome
- Stone Risk Assessment (24-Hour Urine)Identifies metabolic abnormalities in 24-hour urine to guide targeted prevention of recurrent nephrolithiasis
- SVS WIfI ClassificationStratifies threatened limbs by wound, ischemia, and foot infection severity for amputation risk estimation
- TIMI Risk Score (UA/NSTEMI)Estimates mortality and adverse outcomes in unstable angina/NSTEMI
- TIMI Risk Score for STEMIPredicts 30-day mortality in patients with ST-elevation myocardial infarction
- Transtubular Potassium Gradient (TTKG)Assesses renal potassium handling to differentiate causes of hyperkalemia and hypokalemia
- Wells' Criteria for DVTRisk-stratifies patients suspected of deep vein thrombosis to guide diagnostic workup
- Wells' Criteria for PERisk-stratifies patients suspected of pulmonary embolism
Related Specialties
AI Medical Scribe for Hospitalists & Internists
Comprehensive clinical documentation for inpatient and outpatient internal medicine. From complex admission H&Ps to daily progress notes and detailed discharge summaries.
Documentation Challenges in Internal Medicine
- Complex multi-problem patients requiring detailed documentation
- Time pressure from high patient volumes
- Balancing thorough documentation with patient face-time
- Capturing all billable diagnoses for proper reimbursement
- Coordinating care across multiple consultants
Note Types for Internal Medicine
Admission H&P
Comprehensive history and physical for new admissions with full problem list
Daily Progress Notes
SOAP-format notes with assessment and plan for each active problem
Discharge Summaries
Complete discharge documentation with medication reconciliation
Consultation Notes
Specialty consultation responses with recommendations
Key Features for Internal Medicine
Multi-Problem Management
Automatically organizes notes by problem with separate A&P for each
Auto ICD-10 Coding
Captures all relevant diagnoses including HCC codes for risk adjustment
Complete Admission Notes
Multi-problem H&Ps drafted from one recording, with an A&P per problem
HIPAA Compliant
Full HIPAA compliance with signed BAA and encryption
Rounding Mode
Multi-patient encounter tracking for efficient hospital rounding workflows
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