AI Medical Scribe for Family Medicine & Primary Care
Streamlined documentation for outpatient primary care. Annual wellness visits, chronic disease management, preventive care, and everyday office visits.
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Documentation Challenges in Primary Care
Note Types for Primary Care
Purpose-built templates for every encounter type
Office Visit SOAP
Standard SOAP notes for sick visits and follow-ups
Annual Wellness Visit
Comprehensive AWV documentation with health risk assessment
Chronic Care Management
CCM documentation with care plan updates
Preventive Care
Screening documentation with care gap identification
Key Features for Primary Care
Built specifically for your workflow
Quality Measure Tracking
Automatic identification of MIPS and HEDIS measures
Care Gap Detection
Highlights missing preventive care and screenings
Straightforward Visits
Short encounters documented from one recording, no template wrangling
Billing Optimization
Ensures appropriate E&M level capture
Same Patient. Same Encounter.
See why physicians say Scribeable notes are “actually usable” — with integrated risk scores, billing codes, and clinical reasoning that typical AI scribes simply don’t generate.
HPI
55 y/o female here for follow-up of diabetes, hypertension, and depression. A1c was 8.2% last visit. Reports compliance with medications. Checking BMP today. Also reports persistent low mood despite current SSRI. No suicidal ideation. Mammogram and colonoscopy are overdue.
Assessment & Plan
*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
Common Primary Care Conditions
Common Primary Care Procedures
Calculators that can activate in Primary Care
Registry entries whose specialty scope includes Primary Care. Each page lists the inputs the note needs, the scoring criteria, the interpretation bands and the cited sources.
- ABCDE Criteria for MelanomaScreens suspicious pigmented lesions for melanoma using clinical morphologic criteria
- Adult ADHD Self-Report Scale (ASRS)Screens for adult ADHD using a validated 6-item Part A screener
- Ages & Stages Questionnaire (ASQ-3)Screens developmental milestones across 5 domains to identify children needing further developmental evaluation
- 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
- Body Mass Index (BMI)Classifies weight status relative to height to guide nutritional counseling, surgical risk, and metabolic assessment
- C-SSRS (Columbia Suicide Severity Rating Scale)Structured assessment of suicidal ideation and behavior for risk stratification
- CAGE QuestionsScreens for alcohol use disorder
- CHA2DS2-VASc ScoreStratifies stroke risk in non-valvular atrial fibrillation to guide anticoagulation decisions
- CKD-EPI GFREstimates glomerular filtration rate for CKD staging
- 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
- CRAFFT Screening (Adolescent Substance Use)Screens for substance abuse risk in adolescents using a brief validated tool
- DIRE Score (Diagnosis, Intractability, Risk, Efficacy)Predicts suitability for long-term opioid therapy in chronic non-cancer pain
- DN4 Neuropathic Pain QuestionnaireDifferentiates neuropathic pain from nociceptive pain to guide targeted treatment
- 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
- Edinburgh Postnatal Depression Scale (EPDS)Screens for perinatal depression to identify patients needing further evaluation and treatment
- 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
- FRAX Fracture Risk AssessmentEstimates 10-year probability of major osteoporotic and hip fracture to guide treatment decisions
- GAD-7Measures anxiety severity and screens for anxiety disorders
- Geriatric Depression Scale (GDS-15)Screens for depression in elderly patients using a simplified yes/no format
- Gestational Age Calculator (Naegele's Rule)Calculates estimated due date and current gestational age from last menstrual period
- GOLD COPD ClassificationClassifies COPD severity by spirometry and symptom burden using the GOLD 2024 framework for treatment guidance
- HAS-BLED ScoreEstimates 1-year major bleeding risk in AF patients on anticoagulation
- Hoehn and Yahr ScaleStages Parkinson's disease severity based on motor symptom distribution and balance impairment
- Insomnia Severity Index (ISI)Quantifies insomnia severity for diagnosis and treatment monitoring
- Keele STarT Back Screening ToolStratifies low back pain patients into risk groups to guide treatment pathway selection
- LDL Calculated (Friedewald Equation)Calculates LDL cholesterol from standard lipid panel when direct LDL is unavailable
- M-CHAT-R (Modified Checklist for Autism in Toddlers, Revised)Screens for autism spectrum disorder risk in toddlers 16-30 months to prompt early evaluation and intervention
- Modified Centor / McIsaac ScoreEstimates likelihood of group A streptococcal pharyngitis to guide testing and antibiotic decisions
- Modified Medical Research Council Dyspnea ScaleGrades dyspnea severity for COPD symptom assessment and treatment decisions
- Mood Disorder Questionnaire (MDQ)Screens for bipolar spectrum disorders in patients presenting with mood symptoms
- Opioid Risk Tool (ORT)Predicts risk of opioid aberrant behaviors before initiating opioid therapy
- Ottawa Ankle RulesDetermines need for radiography in acute ankle injuries to reduce unnecessary X-rays
- Ottawa Knee RulesDetermines need for radiography in acute knee injuries to reduce unnecessary X-rays
- 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
- PHQ-9Assesses depression severity and screens for MDD
- PHQ-A (Adolescent Depression Screen)Screens for depression in adolescents ages 12-17 using the adapted PHQ-9
- 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.
- Rutherford Classification for PADClassifies severity of peripheral arterial disease for treatment planning
- SHIM/IIEF-5 (Sexual Health Inventory for Men)Screens for and quantifies erectile dysfunction severity to guide treatment approach
- Snellen Visual Acuity InterpretationInterprets Snellen visual acuity measurements and converts to LogMAR equivalents
- SOAPP-R (Screener and Opioid Assessment for Patients with Pain-Revised)Screens for risk of aberrant medication-related behaviors in chronic pain patients
- Wells' Criteria for DVTRisk-stratifies patients suspected of deep vein thrombosis to guide diagnostic workup
- Yale Observation Scale (YOS)Identifies febrile children at risk for serious bacterial illness based on structured clinical observation
Related Specialties
AI Medical Scribe for Family Medicine & Primary Care
Streamlined documentation for outpatient primary care. Annual wellness visits, chronic disease management, preventive care, and everyday office visits.
Documentation Challenges in Primary Care
- 15-minute visit slots with complex patients
- Preventive care gap tracking and documentation
- Chronic disease management across multiple conditions
- Quality measure compliance (MIPS, HEDIS)
- After-hours documentation catching up
Note Types for Primary Care
Office Visit SOAP
Standard SOAP notes for sick visits and follow-ups
Annual Wellness Visit
Comprehensive AWV documentation with health risk assessment
Chronic Care Management
CCM documentation with care plan updates
Preventive Care
Screening documentation with care gap identification
Key Features for Primary Care
Quality Measure Tracking
Automatic identification of MIPS and HEDIS measures
Care Gap Detection
Highlights missing preventive care and screenings
Straightforward Visits
Short encounters documented from one recording, no template wrangling
Billing Optimization
Ensures appropriate E&M level capture
Explore More
Discover how Scribeable can help your practice with AI-powered clinical documentation