Your guide to ScribeMD

This is the core workflow: ScribeMD listens to the consultation, transcribes it, and writes the clinical note from your chosen template. You stay with the patient.

Start the visit

1. Click the blue + button at the top of the left rail. The visit setup screen opens with your microphone level meter at the top.
2. Check that the right microphone is selected and the meter reacts when you speak.
3. Pick the spoken language of the visit and the note template you want (your default is preselected).
4. Optionally open Patient Details to attach a patient, and Consultation Context to paste anything the AI should know (referral reason, previous results).
5. Click Start Consultation. If you already have an audio file, use Upload Audio instead.

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During the recording

1. Telehealth call? Click the headset icon next to the settings gear and pick the browser tab with your call, keeping Also share tab audio on. A green Call audio on badge confirms the patient's side is being captured.
2. The timer runs and the waveform confirms audio is being captured. Do not reload the page while recording.
3. Type anything you want included in the note into Physician Notes (vitals, exam findings, your assessment). It autosaves.
4. Use Pause for interruptions, then resume.
5. When the visit is over, click Generate Note. ScribeMD processes the audio and writes the note; this usually takes well under a minute.

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Review, edit and export the note

1. The note opens on the Notes tab, structured by the sections of your template. Rename the visit with the pencil next to its title.
2. Click Edit to change any section, then Save. Click Copy to put the whole note on your clipboard for your EHR.
3. The Transcription tab shows the full, speaker-labelled transcript. The Documents tab generates letters and forms from the visit (see chapters 4 and 5).
4. The ⋮ menu holds everything else: Download PDF or Word, Duplicate, Resume the visit, Generate Billing Code, Regenerate, Note history, Share Note and Delete.
5. Use the thumbs up / down at the bottom right to rate the note. Feedback improves future notes. Rate it as often as you like, or highlight a passage to comment on just that part. To correct a passage, highlight it, click thumbs down, say what is wrong and choose Submit & Regenerate — only that passage changes (plus any place that repeats the same fact) and the changed words light up. If the correction can't be applied to that passage, Scribe says so and offers to regenerate the whole note (this replaces manual edits).

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Dictation is for when you speak the note yourself, after the patient has left or between visits. ScribeMD transcribes live and cleans the dictation into your template. Dot phrases (chapter 6) expand as you speak.

1. Open the chevron under the + button and choose New Dictation. If dictation is your default visit type, the + button opens it directly.
2. Check the template shown top right (your default is preselected) and give the dictation a title if you like.
3. Click Start Recording and speak. Your words appear in Live Transcript on the left.
4. Click Pause to stop, and Generate Note to turn the transcript into a structured note on the right.
5. To dictate directly into a section of the note, place the cursor in the note and click Dictate. The text is inserted at the cursor.

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Dictate anywhere with the desktop app

The ScribeMD desktop app lets you hold a shortcut key, speak, and have clean text pasted into whatever application is in front of you, including your EHR. Its settings live in the web app under Settings › Productivity › Desktop app and follow your account to any computer.

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A note template defines the sections of your note and the instructions the AI follows for each one. ScribeMD ships with official templates; you can build your own by hand or with AI, share them with your organization, and set one as your default.

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Create a template by hand

1. Click Create Template.
2. Choose Simple (a single free-text SOAP section) or Advanced (multiple sections you fully control).
3. Optionally copy an existing template as a starting point, give it a name, and pick a folder.
4. Leave Make private on to keep it to yourself, or turn it off to share it with your organization. Click Create.

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Edit sections and instructions

1. Each section has a name, an instruction block telling the AI what belongs there, a Required toggle and a style (bullets, numbered, dashes, no bullets, narrative).
2. Drag the handle on the left to reorder sections; use the trash icon to remove one.
3. Add sections with Create Section on the right, or pick from the Predefined Sections library. It includes ready-made Problem List and Medication Reconciliation sections.
4. Scroll down for Custom Instructions that apply to the whole note, then click Save Changes.
5. Use Test template at the top to run the template against one of your past visits before using it live.

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Create a template with AI

1. Click Create with AI in the banner at the top of the page. Describe the template in plain language, or paste an example of a note written exactly the way you want it. Prefer to build it section by section? Click Advanced.
2. Click Send. The builder drafts a full template and shows an Example note next to its Structure.
3. Refine it by typing what to change in the box at the bottom ('add a medications section', 'make the plan a numbered list').
4. When you are happy, click Create Template. It lands in My templates and can be edited like any other.

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Set a default template

1. Open My templates and click Make Default on the template's row.
2. Choose Make my default. Admins can also choose Make default for organization (not available for private templates).
3. The default template is preselected on every new visit and dictation. You can still switch templates per visit.

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Document templates turn a finished visit into a letter or report: referral letters, sick notes, discharge summaries, patient instructions. You write the layout once with placeholders; ScribeMD fills it from each visit.

Create a document template

1. Open the settings gear, then Document Templates in the Clinical group, and click New Document Template. The form opens in a new browser tab.
2. Give it a Name. Tick Make this an organization template if colleagues should be able to use it.
3. In Instructions for AI, explain what the document is for and how it should be written (tone, what to include or leave out).
4. Write the Content in the editor. Use square-bracket placeholders such as [PATIENT_NAME], [DATE] or [REASON_FOR_REFERRAL] where the AI should insert visit-specific text.
5. Click the create button at the bottom. The template appears under My Templates or Organization Templates.

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Generate a document from a visit

1. Open the visit and switch to the Documents tab. In the dictation recorder, open the ⋮ menu above the note and choose Documents instead.
2. Click Generate Document and pick a template from the list (search if you have many). PDF templates appear in the same list with a PDF label.
3. ScribeMD writes the document from the note and transcript. Download it, or open it to make changes.

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PDF templates are for official forms that must keep their exact layout: insurance forms, ministry reports, procedure reports. Upload a fillable PDF, tell ScribeMD what each field means, and it fills the form from the visit.

Upload a fillable PDF

1. Open PDF Templates under the settings gear and click New PDF Template.
2. Choose the PDF file. It must be a fillable PDF (one with form fields). Field detection starts immediately.
3. Optionally give the template a Name, then click Create Pdf template. ScribeMD reports how many fields it found and opens the editor.

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Describe the fields

1. Use General context to describe the form as a whole (who fills it, in which situation). This context is shared with the AI for every field.
2. Fields are drawn over the PDF preview. Click one to select it, then set its Name, an Instruction explaining what should go there, and the font size.
3. Missing fields can be added by dragging a Text, Checkbox, Signature or Date tool from the palette onto the page. Use Prev / Next for multi-page forms.
4. Save. The template now shows under PDF Templates and in the Generate Document list of every visit (chapter 4).

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A dot phrase is a short trigger that expands into a longer block of text you use often: a normal exam, return precautions, counseling you give every time. Say the trigger while dictating, or type it in the note editor, and the full text is inserted.

Create a dot phrase

1. Open Dot Phrases under the settings gear. Your existing phrases are listed with their triggers.
2. Click New Dot Phrase.
3. Give it a Title for your own reference, a short unique Trigger (the words you will say or type), and the Content to insert. Content can include placeholders such as [DATE].
4. Click Create Dot Phrase. Use the pencil and trash icons on each row to edit or delete later.

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Use a dot phrase

1. While typing. Open a note in edit mode (Edit on the visit page, or any note or template editor), place the cursor where the text should go and type a period followed by the trigger, for example .return precautions.
2. Press Space, Tab or Enter. The trigger is replaced by the full content of the phrase. Keep typing, or click Save when the note is done.
3. While dictating. Just say the trigger words (“return precautions”) where the text belongs. The expansion is applied when the dictation is transcribed, so the finished note contains the full text, not the trigger.
4. In generated notes. When ScribeMD writes a visit note, it knows your phrase book and inserts the matching phrase word for word wherever the trigger was said during the visit.

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If the transcript keeps misspelling a drug, a colleague's name, a device or a local place name, add it as a custom keyword. Speech recognition then favours your spelling. Keywords apply to both visits and dictations.

1. Open Custom Keywords under the settings gear.
2. Type the term exactly as it should be written and press Enter (or click +). It is saved immediately.
3. Open Show Terms to review the list; use the search box when the list grows. Click – next to a term to remove it.

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ScribeMD has three separate language settings, and it helps to know which is which. All three live on the My Account page.

1. Click the settings gear. My Account opens.
2. Scroll to the language fields and choose the value you need from each dropdown.
3. Scroll to the bottom and click Save Changes. The interface switches immediately when you change the app language.

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My Account holds everything about how ScribeMD works for you. Change what you need, then click Save Changes at the bottom of the page.

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Light and dark mode

Click the moon / sun icon at the bottom of the left rail to switch themes. The choice is remembered on your account.

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Keyboard shortcuts

Under Settings › Productivity › Keyboard Shortcuts you can enable shortcuts for starting and stopping dictation, generating the note, copying to the clipboard and clearing the recorder. Turn a shortcut on, pick the key combination, and save.

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Organization settings (admins)

Admins also see Organization Settings: the clinic name and address, the patient consent text and whether consent is required before recording, the organization's default note language, and the AI provider used for the whole team.

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Admins and department admins can invite colleagues by email. Invited users join your organization, inherit its templates and settings, and appear on the Medical Team page where you manage roles.

1. Open Medical Team under the settings gear, or click Invite Team Members from your avatar menu at the bottom of the rail.
2. Click Invite Team Members. Type or paste email addresses; separate them with a comma, space or new line. Each address becomes a chip.
3. If your organization uses departments, tick the departments the new users should join.
4. Click Send Invitations. Each person receives an email with a link to set their password.
5. The confirmation dialog also shows each invitation link. Use Copy link to send it yourself if an email is delayed or blocked by a spam filter.

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Roles and departments

1. Change a member's role with the Role dropdown on their row: User for clinicians, Admin for people who manage templates, settings and billing.
2. Give a member Developer access with the code icon in their row's Actions (admins only): whatever their role, they can then manage the organization's API keys.
3. Create departments under Departments to group members (for example by discipline or site). A department can have its own note templates, keywords and custom instructions.
4. Remove a member with the trash icon on their row. Their visits remain in the organization.

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Clinical guidelines turn an official guideline PDF (Lung-RADS, Fleischner, TI-RADS…) into a decision table ScribeMD can follow. Attach a guideline to a note template and every note written with it is checked against the guideline: when the visit documents what the guideline needs, the matching recommendation is added to the note, with the reasoning one click away.

Browse the guideline library

1. Click Guidelines in the left rail. The library lists every guideline you can use, with its version.
2. Official guidelines are published by ScribeMD for everyone; Organization guidelines were added by your organization's admins.
3. Use the search box to filter by name, and click a guideline to open it.

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Add a guideline from its PDF (admins)

1. In the library, click Add Guideline.
2. Enter a Guideline name and choose the Official guideline PDF. Text-based PDFs work best; scanned documents may not extract reliably.
3. Click Upload & Extract. ScribeMD reads the PDF and extracts the guideline's required inputs, decision logic and possible outputs. This takes a minute or two.
4. On Review extraction, compare the original PDF on the left with the extracted logic on the right. When it matches, click Save & Activate. If something is wrong, click Report an Issue instead.
5. Once active, a guideline is read-only and available to everyone in your organization. Corrections are published as a new version, never by editing the active one.

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Use a guideline in a note template

1. Open the note template (chapter 3) and scroll to Clinical Guidelines: below the sections.
2. Search for the guideline and select it. You can attach several.
3. Optionally add instructions for each guideline, for example how short the recommendation should be or what to leave out.
4. Click Save Changes. From now on, every note generated with this template is checked against the guideline.
5. To write the result inside the sections that mention the guideline (for example a grade in Findings and the next step in Plan), tick Use the results within the sections and refer to the guideline in those sections' instructions. A result that fits no section is still added under Recommendations at the end of the note. Without this option, the recommendation always goes under Recommendations.

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Apply a guideline to the whole organization or a department

1. Admins: open Organization Settings and scroll to Clinical guidelines. Department admins: open Departments, pick the department and open its Clinical guidelines tab.
2. Select the guidelines and, if you like, add instructions for each one. Click Save Changes.
3. From then on every note is checked against the organization's guidelines, those of every department its author belongs to, and the template's own. A guideline attached at several levels runs once, with all its instructions.
4. On a template where they don't fit, such as a patient letter, tick Don't apply organization and department guidelines under Clinical Guidelines.

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See the recommendation in the note

1. Record or dictate as usual with that template. Once the note is written, the guideline is evaluated; the note shows Applying clinical guideline… while it runs.
2. When the note contains everything the guideline needs, the recommendation is added under Recommendations, tagged with the guideline's name and version.
3. The Clinical guidelines card under the note lists the values that were read, such as nodule size and type. If something the guideline needs is not documented, the card says so and no recommendation is added.
4. Click View decision table to see each input with the exact quote from the note or transcript, and every step of the decision path that led to the result.
5. With Use the results within the sections, the guideline is evaluated before the note is written and each phrase taken from it appears where the template asks for it, tagged with the guideline's name. Results that fit no section, including organization and department guidelines, are added under Recommendations at the end.

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Before a follow-up, read the patient's story in one place. Summarize Encounters reads every visit attached to a patient and writes a single chart summary: a table of previous sessions (clinician, date and action taken), the event that brought the patient in, and a summary of the notes without the assessment and plan.

Generate the summary

1. Click Patients in the left rail and choose the patient from the list. The search box finds them by name.
2. Check History of Encounters on the right: these are the visits the summary reads. A visit is listed here once the patient is attached to it (chapter 1).
3. Click Summarize Encounters at the top right. The button stays greyed out until the patient has at least one visit.
4. The summary is written into Clinical Notes as it is generated, starting with the previous sessions table. You can leave the page: it keeps going and is there when you come back.

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Review and use it

1. Check the summary against the notes it comes from: click a visit under History of Encounters to open its note.
2. Once a summary is ready, Ask ScribeMD becomes available next to the button, so you can ask questions about the whole chart.
3. Seen the patient again since? Click Summarize Encounters again. The new summary replaces the previous one.

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