Built in Direct Collaboration with Practicing Internal Medicine Physicians

Internal Medicine Notes in Seconds

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Built in direct collaboration with practicing internists, ExamScribe handles the breadth and complexity of internal medicine documentation. Multi-problem chronic disease management, annual wellness visits, hospital follow-ups — complete notes that capture your clinical reasoning without hours at the keyboard.

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ExamScribe — Internal Medicine Encounter
🎤 Your Voice Recording

"55-year-old female here for chronic disease management. Diabetes A1C is 8.1, up from 7.6 last quarter. She's on metformin 1000mg BID and glipizide 10mg daily. She admits she's been less active and eating more carbs. Blood pressure today 148 over 92, she's on lisinopril 10mg. LDL last month was 118, on atorvastatin 40mg. She also has hypothyroidism, TSH was 3.2 last check, on levothyroxine 75mcg. I'm going to add a GLP-1, start semaglutide 0.25mg weekly. Increase lisinopril to 20mg. Recheck labs in 3 months."

📄 Generated Clinical Note
CHIEF COMPLAINT: Chronic disease management — diabetes, hypertension, hyperlipidemia, hypothyroidism HISTORY OF PRESENT ILLNESS: 55-year-old female presenting for chronic disease management follow-up. Multiple active conditions reviewed: Diabetes Mellitus Type 2: A1C 8.1% (increased from 7.6% last quarter). Currently on metformin 1000mg BID and glipizide 10mg daily. Patient reports decreased physical activity and increased carbohydrate intake contributing to glycemic deterioration. Hypertension: BP today 148/92 mmHg. Currently on lisinopril 10mg daily. Suboptimal control. Hyperlipidemia: LDL 118 mg/dL on atorvastatin 40mg. At goal for low-risk patient; reassess ASCVD risk. Hypothyroidism: TSH 3.2 mIU/L (within normal limits) on levothyroxine 75mcg daily. Well-controlled. PHYSICAL EXAMINATION: Vitals: BP 148/92, HR 78, BMI 31.2 General: No acute distress. Cardiovascular: RRR, no murmurs. Pulmonary: Clear bilaterally. Abdomen: Soft, non-tender. Extremities: No edema. Peripheral pulses intact. ASSESSMENT & PLAN: 1. T2DM, suboptimal control — add semaglutide 0.25mg SQ weekly; lifestyle counseling provided; recheck A1C in 3 months 2. Hypertension, uncontrolled — lisinopril increased to 20mg daily; recheck BP in 4 weeks 3. Hyperlipidemia — continue atorvastatin 40mg; LDL at goal 4. Hypothyroidism — well-controlled; continue levothyroxine 75mcg; recheck TSH in 6 months 5. Comprehensive metabolic panel, CBC, lipid panel, A1C in 3 months

Built for How Internal Medicine Physicians Actually Work

Not a generic scribe with "Internal Medicine" added. Every template, every prompt, and every output was purpose-built for internal medicine workflows.

Multi-Problem Chronic Disease Management

Internal medicine visits routinely address 4-6 chronic conditions simultaneously. ExamScribe structures each problem with its own assessment and plan — producing organized, auditable notes that reflect the true complexity of your visits.

Annual Wellness Visit Documentation

Medicare Annual Wellness Visits have specific required elements. ExamScribe's AWV template captures health risk assessment, preventive screening review, cognitive assessment, and personalized prevention plan — ensuring you meet all CMS requirements.

Clinical Reasoning Captured

The "why" behind your decisions is what separates a defensible note from a liability. ExamScribe captures your clinical reasoning — why you changed a medication, why you ordered a test, why you chose watchful waiting — in natural clinical language.

Internal Medicine-Specific Context Template Builders

AI can hear your words but cannot see your exam. These structured builders push real clinical findings to the AI in one click — eliminating hallucination and ensuring every note reflects what you actually did.

Chronic Disease Management

Multi-problem visit with individual problem assessment/plan, lab correlation, medication adjustments

Annual Wellness Visit (AWV)

CMS-required elements, health risk assessment, preventive screening, cognitive screening, prevention plan

Diabetes Management

A1C trend, medication regimen, hypoglycemia history, complication screening, DSMES referral

Hypertension Management

BP readings, medication adherence, end-organ damage, lifestyle modification, target documentation

COPD Management

GOLD classification, spirometry, exacerbation history, inhaler technique, pulmonary rehab

Anemia Workup

CBC indices, iron studies, B12/folate, reticulocyte count, differential diagnosis, treatment plan

Hypothyroidism / Hyperthyroidism

TSH trend, symptom review, medication adjustment, monitoring plan

Obesity Management

BMI, comorbidity assessment, dietary/activity counseling, pharmacotherapy, bariatric referral

UTI / Infectious Disease

Symptom duration, UA/culture results, antibiotic selection, resistance considerations

Pneumonia Management

PSI/PORT score, severity assessment, antibiotic selection, admission vs outpatient decision

Integrated Compliance Engine

Internal Medicine E/M Audits Are Increasing. Is Your Documentation Keeping Up?

CMS has shifted E/M coding to medical decision-making — but many internists are still documenting as if the old history/exam counting rules apply. ExamScribe's compliance engine ensures your notes reflect the complexity you're actually delivering and support the level you're billing.

Medical Decision-Making Under 2021 E/M Rules

The 2021 AMA E/M revisions changed how office visits are coded. The engine verifies your note documents the three MDM elements — problem complexity, data reviewed, and risk — at the level required for your billed code.

Annual Wellness Visit vs. Office Visit

AWVs and preventive visits have different billing rules than problem-focused E/M visits. The engine flags when a visit contains elements that should be billed separately or when required AWV elements are missing.

Chronic Care Management Documentation

CCM billing (99490, 99491) requires documented care plan, time tracking, and coordination activities. The engine checks that your documentation supports CCM billing when applicable.

Medication Management Documentation

Prescription drug management is a key MDM element. The engine verifies that medication changes are documented with clinical rationale — not just listed as a plan item.

Preventive Screening Documentation

Preventive services require documented counseling and clinical indication. The engine checks that ordered screenings have documented rationale — protecting against payer audits of preventive service billing.

Two-Pass AI Compliance Audit

Every note is analyzed for coding accuracy, documentation sufficiency, and payer-specific requirements. You receive a detailed gap report — reviewed and attested by you before any changes are made.

Three Steps. That's It.

Start generating notes in under a minute.

1

Record

Click record and speak naturally about the encounter — during the visit, after the visit, or just key findings. No special commands.

2

Generate

ExamScribe transcribes your recording and generates a complete, properly structured internal medicine note with accurate specialty terminology in seconds.

3

Review & Export

Review the note, make any quick edits, and copy it into your EHR or export as PDF. Done.

Simple, Transparent Pricing

One plan. Everything included. No per-note fees.

Individual Physician
MonthlyAnnual Save $120/yr
$89/mo

billed annually ($1,068/yr)

  • 400 AI credits per month
  • All Internal Medicine template builders
  • Compliance audit engine
  • Document analysis & appeal letters
  • Voice-to-note in seconds
  • PDF & Excel export
  • HIPAA compliant — signed BAA included
  • 30-day free trial
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Your Patients' Data Is Sacred

Built with the same standard of care you bring to your patients.

HIPAA Compliant

  • Signed Business Associate Agreement
  • AES-256 encryption at rest
  • TLS 1.2+ in transit
  • SOC 2 Type II Azure data centers (US only)

Zero Data Sharing

  • Transcripts never used to train AI
  • No third-party data sharing — ever
  • Data never leaves US servers
  • You own your data — delete anytime

Automatic Protection

  • No audio recordings stored
  • Auto-delete on your schedule
  • Complete audit logging
  • Session timeouts enforced

Frequently Asked Questions

Can ExamScribe handle visits with multiple chronic conditions?

Yes. ExamScribe is specifically designed for the multi-problem complexity of internal medicine. It structures each active problem with its own assessment and plan, producing organized notes that reflect the true complexity of your visits.

Does ExamScribe support the 2021 E/M coding changes?

Yes. ExamScribe documents the elements of medical decision-making complexity required under the 2021 AMA E/M guidelines — problem complexity, data reviewed, and risk of management. This directly supports accurate E/M level selection.

Can ExamScribe help with Medicare Annual Wellness Visit documentation?

Yes. The AWV template builder captures all CMS-required elements including health risk assessment, preventive screening review, cognitive assessment, and personalized prevention plan — ensuring you meet all requirements for AWV billing.

How does ExamScribe handle hospital follow-up and transition of care visits?

ExamScribe includes templates for post-discharge follow-up and transition of care management. These visits have specific documentation requirements for TCM billing (99495, 99496) that the compliance engine verifies.

Is my patient data used to train the AI?

Never. Your transcripts and patient data are never used to train AI models. All data is processed on HIPAA-compliant Azure servers in the US and auto-deleted on your schedule.

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