CLINICAL NOTE GENERATION — AI MEDICAL SCRIBE
Every SOAP note, H&P, progress note, and discharge summary — structured, complete, and billable — generated from conversation in under 60 seconds.
SUBJECTIVE
58F presenting with progressive exertional dyspnea ×3 weeks. Denies chest pain, orthopnea. PMH: HTN, T2DM. Current meds: metformin 1g BID, lisinopril 10mg.
OBJECTIVE
Vitals: BP 148/92 · HR 88 · SpO₂ 94% · RR 18. Exam: Mild bibasilar crackles. No JVD. Trace bilateral pedal edema.
ASSESSMENT
New-onset heart failure vs. atypical pneumonia. Hypertension, suboptimally controlled. Diabetes mellitus, type 2 — unchanged.
PLAN
BNP, CXR, Echo ordered. Furosemide 40mg PO × 3 days. Increase lisinopril to 20mg. Follow-up 5 days or sooner if symptoms worsen.
THE DOCUMENTATION CRISIS
Not in time spent. In cognitive load. Every note demands memory, structure, coding knowledge, and compliance awareness — simultaneously. The AI doesn't forget any of it.
16min
Average time a physician spends on a single note — across all note-taking sessions for one visit.
4.5hr
Daily EHR time for a typical primary care physician. More than half is documentation.
$68K
Annual cost per physician of documentation-related productivity loss, per AMA research.
34%
Of notes require rework due to incomplete documentation, missing elements, or coding errors.
NOTE FORMATS SUPPORTED
Peerbits AI Scribe ships with 14 pre-built note templates mapped to specialty workflows — and a custom builder for anything your EMR team has configured internally.
Subjective, Objective, Assessment, Plan — the universal outpatient note format, generated with complete HPI, full ROS, MDM complexity scoring, and ICD-10 auto-mapping.
Full admission history and physical for hospital encounters — includes complete past medical/surgical/family/social history and comprehensive system review.
Daily inpatient updates formatted for attending rounds — captures interval events, current vitals, labs, imaging, and updated assessment and plan.
Captures the full inpatient episode — admission diagnosis, hospital course, procedures, discharge medications, follow-up instructions, and condition at discharge.
Purpose-built for therapy and psychiatry sessions. Captures mood, affect, insight, risk assessment, treatment response, and therapeutic interventions used.
Dictation-friendly format for post-procedure documentation. Captures procedure name, surgeon, indication, technique, findings, complications, and specimen details.
THE AI ENGINE
Generic AI writes text. Peerbits AI Scribe understands clinical context — differentials, symptom-diagnosis relationships, medication relevance, and billing implications — before it writes a word.
Separates physician from patient voice with >96% accuracy. Understands medical accents, specialty shorthand, and clinical abbreviations without a glossary.
Identifies symptoms, diagnoses, medications, dosages, allergies, procedures, and temporal references — tagging each with confidence scores before note assembly.
Routes extracted content into the correct note sections — never invents clinical detail, never omits a required field. Flags incomplete HPI elements before sign-off.
Auto-suggests primary and secondary diagnosis codes with specificity required for claim submission. Calculates E&M MDM complexity and flags documentation gaps that risk downcoding.
Pushes the signed note via FHIR R4 to Epic, Cerner, athenahealth, or Meditech. No copy-paste. No dual-entry. No middleware delays.
INPUT · CLINICAL TRANSCRIPT
"...the knee pain is worse going down stairs, started after her half-marathon six weeks ago. She tried ibuprofen, some relief. No instability, no locking, no swelling. On exam, positive patellar grind, no effusion, intact ligaments..."
↓ AI ENGINE · 1.4s
SUBJECTIVE
32F presenting with anterior knee pain, onset 6 weeks following half-marathon. Worse with stair descent. Partial relief with OTC ibuprofen. Denies instability, locking, effusion.
OBJECTIVE
Positive patellar grind test. No joint effusion. Ligamentous exam intact bilaterally. ROM full.
ASSESSMENT
Patellofemoral pain syndrome (runner's knee), right knee.
ICD-10 AUTO-MAPPED
E&M LEVEL
99213 · Low complexity MDM · Office/Outpatient Est.
ACCURACY & PERFORMANCE
Clinical AI only earns adoption when its accuracy is measurable. Every metric below is tracked in production across live deployments — not benchmark datasets.
96%
Physician first-pass acceptance rate — notes signed without edits
98.2%
Clinical entity recall — symptoms, meds, and diagnoses captured correctly
94%
ICD-10 first-code accuracy — matching physician's own code selection
<60s
End-to-end note delivery from visit end to signed EHR entry
0
Clinical hallucinations — our engine flags gaps, never invents detail
SPECIALTY COVERAGE
| Specialty | Primary Note Format | Key AI Features | Avg. Note Time |
|---|---|---|---|
| Family Medicine / Internal Medicine | SOAP | Multi-problem visit, preventive care, chronic disease tracking | 38s |
| Psychiatry | DAPBIRP | Mood/affect tagging, risk stratification, medication response | 44s |
| Orthopedics | SOAPOperative | Anatomical precision, laterality, functional status, CPT coding | 32s |
| Emergency Medicine | ED Note | Rapid assessment, interruption-resilient, triage level auto-calc | 29s |
| Hospitalist / Internal Medicine | H&PProgressDischarge | Full inpatient episode, rounding efficiency, transitions of care | 52s |
| Pediatrics | Well VisitSOAP | Age-appropriate milestones, growth charts, immunization capture | 41s |
| Cardiology | SOAPConsult | Echo findings, stress test interpretation, cardiac risk scoring | 47s |
COMPLIANCE & SECURITY
Clinical documentation carries legal weight. Every note Peerbits AI Scribe generates is designed to meet physician, payer, and regulatory requirements — not just clinical ones.
PHI encrypted at rest (AES-256) and in transit (TLS 1.3). Audio discarded post-processing. BAA executed as standard.
Notes structured to satisfy CMS E&M guidelines, with MDM complexity documented to support billing level claimed.
Every AI-generated note carries a full audit log: source transcript, entity extraction output, model version, and physician review timestamp.
Annual third-party security audits. Penetration testing reports available on request for security review committees.
The AI flags missing required fields rather than filling them with plausible fiction. Incomplete sections are surfaced for physician completion.
THE WORKFLOW
No training week. No workflow redesign. Physicians are generating notes on day one.
STEP 01
Choose SOAP, H&P, or any configured specialty template before or during the visit.
STEP 02
Talk naturally. The AI listens. No scripted phrases, no keywords, no prompts required.
STEP 03
A complete structured note appears within 60 seconds — including ICD-10 codes and MDM complexity.
STEP 04
Read the note alongside the source transcript. Adjust any section — or sign it as generated.
STEP 05
One click sends the signed note directly to the patient's EHR record. No copy-paste. No re-entry.
"A clinical note isn't a summary of your visit. It's a legal record, a billing instrument, and a care handoff — all at once. The AI has to get all three right."
— Engineering philosophy, Peerbits AI Scribe Clinical Note Engine
See how health systems are using Peerbits AI Scribe to reclaim physician time and improve documentation quality.
Healthtech ,
Remote patient monitoring app helps to bridge the gap between patients and healthcare providers. It tracks the vitals of the patients and sends it to the doctors.
Healthtech , AWS / Cloud ,
A healthcare startup struggled with increasing loads of data and manual infrastructure management as its business expanded. Peerbits successfully built cloud infrastructure using AWS for their system possessing auto-scaling, automated and more.
Healthtech ,
This is a native iOS app that helps to bridge the gap between the patients and healthcare providers. Patients can monitor their health on a regular basis and share the data with the doctors and healthcare professionals.
Yes — and 96% of physicians do exactly that after the first week. However, you always have the option to review before signing. The note is yours the moment it's generated; the AI's role ends at the draft. Physician signature is required, and remains the legal attestation of clinical content.
The note appears alongside the full source transcript, synchronized by timestamp. Any discrepancy is immediately visible. Physicians can correct the note inline or regenerate a specific section. Every correction feeds the physician's personal model, improving accuracy over time for their individual speech patterns and clinical style.
No — and this is a hard architectural constraint, not a policy. Our model is trained to surface gaps rather than fill them. If an HPI element wasn't discussed, the field is flagged as incomplete. The AI will never suggest a finding that wasn't documented in the conversation.
The AI suggests primary and secondary codes based on the clinical content, with specificity ranked by confidence score. You can accept, modify, or replace any suggested code before signing. The system also tracks your override patterns and adjusts future suggestions to match your coding preferences.
We ship native connectors for Epic (Certified), Cerner Oracle Health, athenahealth, Meditech Expanse, and eClinicalWorks. Any FHIR R4-compliant EHR can receive notes via our API. Custom EHR integrations are available as part of our enterprise deployment, typically completed within 2–4 weeks.
Yes. The template builder lets you define section names, field requirements, default language, and even required ICD-10 code families — all without developer involvement. Custom templates are version-controlled and can be shared across your group or scoped to individual physicians.
Have more questions?
Ask our expertsREADY TO SEE IT LIVE
30 minutes. No slides. We run a live demonstration using a scenario from your specialty — so you can judge the output yourself.
Expert insights on AI clinical documentation, note generation, and healthcare technology.
