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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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"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."
Not a generic scribe with "Internal Medicine" added. Every template, every prompt, and every output was purpose-built for internal medicine workflows.
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.
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.
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.
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.
Multi-problem visit with individual problem assessment/plan, lab correlation, medication adjustments
CMS-required elements, health risk assessment, preventive screening, cognitive screening, prevention plan
A1C trend, medication regimen, hypoglycemia history, complication screening, DSMES referral
BP readings, medication adherence, end-organ damage, lifestyle modification, target documentation
GOLD classification, spirometry, exacerbation history, inhaler technique, pulmonary rehab
CBC indices, iron studies, B12/folate, reticulocyte count, differential diagnosis, treatment plan
TSH trend, symptom review, medication adjustment, monitoring plan
BMI, comorbidity assessment, dietary/activity counseling, pharmacotherapy, bariatric referral
Symptom duration, UA/culture results, antibiotic selection, resistance considerations
PSI/PORT score, severity assessment, antibiotic selection, admission vs outpatient decision
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.
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.
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.
CCM billing (99490, 99491) requires documented care plan, time tracking, and coordination activities. The engine checks that your documentation supports CCM billing when applicable.
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 services require documented counseling and clinical indication. The engine checks that ordered screenings have documented rationale — protecting against payer audits of preventive service billing.
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.
Start generating notes in under a minute.
Click record and speak naturally about the encounter — during the visit, after the visit, or just key findings. No special commands.
ExamScribe transcribes your recording and generates a complete, properly structured internal medicine note with accurate specialty terminology in seconds.
Review the note, make any quick edits, and copy it into your EHR or export as PDF. Done.
One plan. Everything included. No per-note fees.
billed annually ($1,068/yr)
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Built with the same standard of care you bring to your patients.
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.
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.
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.
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.
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.
Join internal medicine physicians who are spending less time on documentation and more time with patients.
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