AI Scribe
Visit documentation
Patel, Maya
Tap Record visit, speak naturally, then tap stop — Deepgram transcribes, Claude writes the SOAP. Or paste / type the transcript below.
S: Maya presents reporting neck pain and cervicogenic headaches as her chief complaint. Pain rated 3/10 today. No prior visit history on file for comparison.
O: Transcript documents cervical region as treatment area. Specific palpation findings, posture, ROM measurements, and orthopedic test results were not documented during this visit. Adjustment performed to cervical spine; specific segmental levels and listings not clearly stated in transcript. Note: provider referenced 'L5, L6' — no such lumbar segment exists; it is unclear whether lumbar spine was intended or whether this was a dictation error referencing cervical levels.
A: Cervicogenic headache (G44.309) with cervical segmental dysfunction (M99.01) as working impression for new patient. Insufficient transcript detail to fully characterize objective findings or establish measurable functional baseline.
P: Cervical adjustment performed per provider. No modalities, HEP, or home-care instructions documented in transcript. RTC frequency and care plan not yet established; recommend formalizing care plan at next visit.
Running the generator again inserts another SOAP version for this visit.
Advanced — file upload & debug›
Short audio file instead of the built-in mic.
Dev: Deepgram token
Type the note directly when you didn’t record, or to append another version. Saves a new SOAP version on this visit — does not call the AI.