Updated on: July 15, 2025

📝 Introduction

Accurate, timely clinical documentation is essential, yet writing notes remains one of the most time-consuming tasks for providers. Nearly half of clinicians report burnout related to documentation overload. To address this, medical scribes—whether human or AI—use structured templates across various encounter types. This guide explores the top seven scribe note types, highlights work-saving examples, and shows how DocScrib enhances scribing with intelligence and ease.

📈 The 7 Most Common Medical Scribe Notes

The following core note types cover the bulk of clinical documentation:

1. History & Physical (H&P)
2. Consultation Note
3. Diagnostic Test / Lab Note
4. Progress Note (SOAP)
5. Pre-/Postoperative Note
6. Procedure Note
7. Discharge Summary

🔧 Detailed Example: History & Physical (H&P)

Use Cases: New patient exams, pre-op evaluation, longitudinal follow-ups.
Structure:

• Chief Complaint (CC)
• History of Present Illness (HPI)
• Past Medical / Surgical History
• Medications & Allergies
• Social / Family History
• Review of Systems
• Physical Exam
• Assessment & Plan

Sample Snapshot:

CC: 45-year-old male with chest pain.  
HPI: Substernal pressure onset 2 hrs ago…  
ROS: Denies dyspnea, fever; endorses nausea.  
PE: BP 138/86, HR 82, RR 18, S1/S2 normal.  
A/P: Rule out ACS → ECG, troponin levels q3 hrs, start ASA 325 mg.

🔧 Progress Notes (SOAP)

The SOAP structure serves as a clear snapshot during ongoing care.

Example:

S: “My headaches are daily, 5/10.”  
O: BP 130/80, neuro exam unremarkable.  
A: Likely tension HA.  
P: Continue ibuprofen, monitor, follow-up in 2 weeks.

🔎 Other Note Types

• Consultation Notes: Focused on recommendations from external specialists.
• Diagnostic Test Notes: e.g., interpretation of ECGs, labs.
• Pre-/Post-Op & Procedure Notes: Document risk, consent, steps, patient response.
• Discharge Summaries: Key for care transitions; includes events, outcomes, and follow-up plans.

Structured templates reduce errors and cognitive load, making documentation faster and more consistent.

📊 Efficiency Gains: Charting the Impact

Switching to templates and AI scribes yields significant time savings, freeing clinicians to focus on patient care.

🎥 Video Walkthrough Suggestions

1. How to Write SOAP Notes
2. AI Medical Scribe in Action
3. Efficient EHR Documentation with AI

These videos provide practical demonstrations of real-world note-taking scenarios and AI-powered efficiencies.

🔍 Real-World Feedback

Clinicians using AI scribes have reported:

• Notes that previously took 20+ minutes now completed in under 5 minutes.
• Reduced after-hours charting.
• Improved provider satisfaction and presence during patient visits.

📊 DocScrib + AI Scribe: Amplifying Impact

While AI scribes produce structured notes, DocScrib enhances the experience by:

• Auto-formatting into SOAP, H&P, discharge templates.
• Identifying missing details (e.g., allergies, vitals).
• Learning individual provider styles over time.
• Seamlessly exporting to any EHR system.
• Ensuring full compliance with HIPAA and SOC2.

Time saved with DocScrib:

• H&P: ~15–20 minutes saved.
• SOAP: ~5–8 minutes saved.
• Discharge: ~20–25 minutes saved.

🧠 Evidence & Validation

Studies show AI-generated notes match or nearly match human quality. Evaluations score AI notes within 95% of clinician-prepared notes, while cutting documentation time dramatically. These findings underscore the reliability and efficiency of AI scribe solutions when paired with intelligent tools like DocScrib.

✅ Final Takeaways

• Templates combined with AI scribes transform note-taking into an efficient, clinician-friendly process.
• The seven key note types cover most documentation needs.
• DocScrib enhances AI outputs with compliance, customization, and seamless integration.
• The result: faster notes, reduced burnout, improved care delivery.

📢 Ready to revolutionize your clinical documentation? Try DocScrib and experience the difference in speed, accuracy, and satisfaction.