ScribeMDPro

PM&R

Physiatry documentation with rehab planning intact

Post-stroke rehab, spasticity, MSK, EMG — ScribeMDPro drafts PM&R notes with the plan detail these patients require.

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Physical medicine and rehabilitation blends outpatient MSK medicine, post-injury or post-stroke rehabilitation, spasticity management with botulinum injections, and electrodiagnostic testing. Documentation demands vary substantially by visit type — a spasticity injection visit needs procedure detail, while a post-stroke rehab visit needs functional goals and progress. ScribeMDPro was configured with PM&R templates that capture functional goals, rehab progress and procedural detail as appropriate to the visit type.

Documentation challenges we solve

  • Rehabilitation progress must be documented against specific functional goals
  • Spasticity injection visits require site, muscle, dose and technique documentation
  • EMG/NCS interpretation is dense and benefits from structured formatting
  • Cross-discipline communication with PT/OT/SLP requires clean plan output

What clinicians gain

  • Rehabilitation template with functional goals and progress tracking
  • Spasticity injection template with site, muscle, agent and dose per injection
  • EMG/NCS interpretation formatted for readability
  • Rehab plan output shareable with PT, OT and speech-language pathology

How it works

  1. Step 1
    Start ambient capture

    Open ScribeMDPro before the PM&R encounter and start recording — the patient never has to talk to a device.

  2. Step 2
    Focus on the patient

    Conduct your normal history and exam. Perform your assessment or injection visit as usual — the AI captures functional goals or procedural details as appropriate.

  3. Step 3
    Auto-drafted note

    A structured SOAP note appears seconds after the visit ends, formatted for your specialty.

  4. Step 4
    Review, sign, export

    Edit inline, copy to your EMR, download as PDF, or push through supported integrations.

Example SOAP output

S: 62yo M 8 weeks post-right MCA stroke with residual left spastic hemiparesis. Functional goals: ambulate 100ft with cane, improve left UE reach. PT progressing.
O: Left UE: MAS 2 elbow flexors, MAS 2 wrist flexors. Left LE: MAS 1+ gastrocnemius. Gait: hemiplegic pattern, 60ft with contact-guard.
A: Post-stroke spasticity limiting rehabilitation progress.
P: Botulinum toxin injections — biceps 100u, FCR 50u, FCU 50u, gastrocnemius 100u. Continue PT/OT. Recheck 6 weeks.

Illustrative only. Clinicians retain final responsibility for the record.

Frequently asked questions

Does it document rehab goals and progress?

Yes. Functional goals are captured explicitly and progress is trended across visits.

Can it capture spasticity injection details?

Injection visits are supported with muscle-by-muscle site, agent and dose capture.

How does it handle EMG interpretation?

EMG/NCS interpretation is formatted for readability with study-by-study findings.

Does it work in inpatient rehab?

Inpatient rehab rounding is supported with an abbreviated template optimized for daily notes.

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