Psychiatry

A scribe that protects the therapeutic alliance

Psychiatry demands presence. ScribeMDPro drafts MSE, medication plans and risk assessments without a keyboard between you and the patient.

In psychiatry, the therapeutic alliance is not a soft outcome — it is the treatment. Anything that comes between clinician and patient during the session degrades the encounter. Traditional documentation forces the psychiatrist to type during the hour, or spend equal time after the session reconstructing what happened. ScribeMDPro removes both. The ambient model listens through the encounter and produces a structured note that includes mental status exam, session content, medication management, risk assessment and plan, while leaving the psychiatrist fully present. The output was designed with psychiatrist reviewers to respect the specialty's specific documentation requirements, including differentiating psychotherapy content from medication management.

Documentation challenges we solve

  • Typing during a psychiatric session damages the therapeutic alliance
  • Mental status exam has 8+ standard domains, each requiring nuanced observation
  • Risk assessment (SI/HI, means, protective factors) must be documented explicitly and consistently
  • Psychotherapy add-on billing (90833/90836/90838) requires separating therapy content from E/M content

What clinicians gain

  • Full MSE template populated from ambient observation and patient interaction
  • Structured risk assessment (SI, HI, means, plan, intent, protective factors)
  • Clean separation of E/M content and psychotherapy content for billing accuracy
  • Preserves patient statements verbatim where clinically important

How it works

  1. Step 1
    Start ambient capture

    Open ScribeMDPro before the psychiatry 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. Conduct the session normally — the AI produces MSE, session narrative, medication management and risk sections.

  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: 29yo F with MDD, GAD returns for follow-up. Since starting sertraline 100mg 6 weeks ago, reports mood 'noticeably better', sleep improved, anxiety attacks reduced from daily to 1–2x/week. No SI/HI. Denies side effects.
MSE: Alert, cooperative, good grooming. Speech normal rate/rhythm. Mood 'much better'. Affect euthymic, congruent. Thought process linear. No SI/HI/AH/VH. Insight and judgment good.
A: MDD improving on SSRI. GAD partial response.
P: Continue sertraline 100mg daily. Consider increase to 150mg if incomplete response at next visit. Continue CBT weekly. RTC 4 weeks.

Illustrative only. Clinicians retain final responsibility for the record.

Frequently asked questions

Does it document mental status exam automatically?

Yes. All standard MSE domains are populated from ambient observation and patient interaction during the session.

How does it handle psychotherapy content?

Therapy content is captured in a separate section from E/M content, supporting accurate add-on code billing.

Is patient audio ever retained?

Retention is configurable per clinic. Many psychiatric practices choose immediate audio deletion after transcript generation.

Does it capture risk assessment consistently?

Risk sections use a structured template (SI, HI, means, plan, intent, protective factors) rather than free text.

Related pages

Try ScribeMDPro on your next visit

Start free — no credit card, no install. Sign up in under a minute and record your first ambient SOAP note today.