Información, actualizaciones y recursos para profesionales de la salud
A complete normal physical exam template by body system, a focused exam example, a head-to-toe assessment checklist, and rules for using templates honestly.
A copy-ready SOAP note template, three worked SOAP note examples from primary care and therapy, and the habits that make each section short and useful.
A practical guide to writing a mental health treatment plan: what goes in it, how to write measurable objectives, a full worked example, and how to keep it current.
A practical guide to the mental status exam: each component, what to write, a full example note, and where an ambient AI scribe helps and where it can't.
A biopsychosocial assessment is the longest note most behavioral-health clinicians write. Here's what it covers, how to keep it usable, and where an ambient AI scribe can take some of the weight.
The history of present illness is the part of the note your colleagues read first. Here's the format, the eight classic elements, an example, and how an ambient AI scribe drafts it from the visit.
The review of systems still matters, just not the way it used to. Here's what the 14 systems are, what changed with office E/M coding, and how to keep an ROS useful instead of cloned.
“Ambient clinical documentation” is the enterprise name for AI that drafts notes from the visit. Here’s what the term means in practice — and what to ask before you buy.
BIRP notes track what the client did, what you did, how they responded, and what comes next. Here is how the format works in real sessions — and how an AI scribe can draft it without stealing the hour after clinic.
DAP notes break a behavioral-health visit into Data, Assessment, and Plan. Here is what each section is for, where clinicians get stuck, and how an ambient AI scribe can draft them without turning the session into paperwork.
Medical dictation software turns speech into text. Ambient AI turns the visit into a draft note. Here’s how to tell which one you actually need.
Need evidence-backed answers at the point of care — not another generic chatbot? Here’s how ScribeMD Answers compares when you’re evaluating an OpenEvidence alternative.
